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  • Publication # 14-RA001

Pay-for-performance program does not improve diabetes care

Patient Safety and Quality

Pay-for-performance (P4P) programs are designed to reward providers with payment incentives when they improve or deliver quality health care. One strategy is to pay out "piece-rate" bonuses for each patient when a particular care goal is achieved. A new study found this approach disappointing in improving diabetes care and outcomes in low-income patients, with quality measures not improving significantly during the study. 

Researchers evaluated a P4P diabetes program launched at a not-for-profit Medicaid-focused managed care health plan in 2003. Out of 100,000 enrollees, 7 percent had diabetes. Providers were offered $100 for each patient that completed all four required clinical tests for diabetes care: HbA1c (measure of blood-sugar level), LDL-cholesterol, dilated retinal exam (to detect diabetes-related complications), and microalbuminuria (test for urine protein to detect diabetes-related kidney damage). 

During subsequent years, bonuses increased significantly and quality measures were added, such as if HbA1c and LDL were at their targeted goal levels. Plan-level administrative data and patient-level claims data were analyzed. In addition, a brief survey was conducted in 2009 to obtain information on diabetes-related quality improvement activities.

No significant changes in diabetes care process or outcomes were observed during the study period. The researchers, however, did find some differences in care patterns. Women were significantly less likely than men to be seen in the emergency department (ED) or hospitalized for diabetes. Younger patients with diabetes (between 18 and 30 years of age) were significantly less likely to have an office visit. This group also had more than three times the odds of visiting the ED or being admitted to a hospital. 

The researchers note that recent health legislation now requires using P4P incentives in government programs that care for minority and low-income patients. They call for more research to identify ways diabetes P4P programs can be tailored to these vulnerable populations. The study was supported in part by AHRQ (HS17146). 

See "Impact of a pay for performance program to improve diabetes care in the safety net," by Alyna T. Chien, M.D., M.S., Diana Eastman, Zhonghe Li, M.S., and Meredith B. Rosenthal, Ph.D., in Preventive Medicine 55, pp. S80-S85, 2012.


Page last reviewed October 2013
Internet Citation: Pay-for-performance program does not improve diabetes care: Patient Safety and Quality. October 2013. Agency for Healthcare Research and Quality, Rockville, MD.


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