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Buy-Right for Health Care Quality: Evidence and Indicators: Paying for Performance

Slide Presentation by Gary Young, J.D., Ph.D.

On October 21, 2004, Dr. Young made a presentation in a Web conference entitled Buy-Right for Health Care Quality: Evidence and Indicators: Paying for Performance.

This is the text version of Dr. Young's slide presentation. Select to access the PowerPoint® Slides (112 KB).

Evaluation of the Rewarding Results Program

Gary Young, J.D., Ph.D.
Boston University School of Public Health and
Department of Veterans Affairs
Boston, MA

Slide 1

Rewarding Results: Seven Demonstration Projects

This slide contains a table of the seven demonstration projects. There are three columns displayed in the table. The first column is labeled "Demonstration Project." The second column is labeled "Unit of Accountability." Lastly, the third column is labeled "Geographic Region." The seven demonstration projects described in the table are:

1)Blue Cross Blue Shield of Michigan; Unit of Accountability: "Hospitals"; Geographic Region: "MI"
2)Blue Cross of California; Unit of Accountability: "Individual Physicians"; Geographic Region: "San Francisco Bay Area"
3) Bridges to Excellence; Unit of Accountability: "Individual physicians and group practices"; Geographic Region: "Cincinnati, OH; Louisville, KY; Boston, MA; Albany, NY"
4)Excellus; Unit of Accountability: "Individual physicians"; Geographic Region: "Rochester, NY"
5) Pay-for-Performance—Integrated Healthcare Association; Unit of Accountability: "Group Practices"; Geographic Region: "CA"
6) Local Initiative Rewarding Results—Center for Health Care Strategies; Unit of Accountability: "Individual physicians and group practices"; Geographic Region: "CA"
7) Massachusetts Health Quality Partners; Unit of Accountability: "Group Practices"; Geographic Region: "MA"

Slide 2

Quality Targets

  • Selected quality targets.
  • HbA1c screening.
  • Diabetic eye exam.
  • Mammography.
  • Well-child visits.
  • Scoring.
  • 75% threshold.
  • 67%, 75% thresholds.
  • 83% threshold.
  • % improvement.

Slide 3

Financial Incentives Arrangements

  • Withhold (5%-20% of claims) .
  • Block bonus potential to group (e.g., $60,000/40 primary care physicians; $1.2 million/280 primary care physicians).
  • PMPM bonus potential for total panel (e.g., $1.50 per member per month; $3.00 per member per month).
  • Hybrid: withhold and bonus.
  • Enhanced fee schedule in subsequent year.

Slide 4

Conceptual Framework: Financial Incentives and Quality

This slide contains a model that demonstrates the conceptual framework through four boxes representing an item of the model and arrows indicating an influential force on each inclusive item. The four boxes are:

  1. Provider Perceptions:
    1. Awareness.
    2. Financial salience.
    3. Scientific/clinical credibility.
    4. Scope of control.
    5. Fairness.
    6. Unintended consequences.
  2. Feedback.
  3. Practice Behavior.
  4. Quality Targets.

"Provider Perceptions" affect "Practice Behavior" and are influenced by "Feedback." "Practice Behavior" affects "Feedback" and "Quality Targets." "Quality Targets" affect "Feedback." "Feedback" affects "Provider Perceptions."

Slide 5

Survey Results: Physician Attitudes toward Incentives in General

This slide contains a table which represents surveyed physician attitudes. On the left are four statements:

  • Physicians should be rewarded for higher quality (5.0% Strongly disagree, 5.1% disagree, 12.5% are neutral, 45.4% agree, and 32.1% strongly agree).
  • Financial Incentives are an effective way to improve quality (7.8% Strongly disagree, 16.5% disagree, 20.7% are neutral, 41.9% agree, and 13.1% strongly agree).
  • Financial Incentives are most effective when linked to individual performance (5.1% Strongly disagree, 11.5% disagree, 22.8% are neutral, 46.6% agree, and 13.7% strongly agree).
  • Efforts to achieve targets may hinder provision of other medical services (8.2% Strongly disagree, 43.2% disagree, 27.4% are neutral, 18.1% agree, and 3.1% strongly agree).

At the bottom are percentage rates from 0-100%. The response choices for each statement are labeled, "Strongly Disagree, Disagree, Neutral, Agree, Strongly Agree."

There were 714 respondents in this study.

Slide 6

Survey Results: Physician Attitudes Toward a Specific Incentive Program

This slide contains a line graph which shows the attitudes of physicians on specific characteristics of an incentive program. There are two line graphs. Site A, is represented by a solid line, and Site B is represented by a dotted line. On the left is a scale from 1-5 in which the physician response was rated from 1 - 5. A ranking of 1 means strongly disagree. A ranking of 5 means strongly agree.

The eight characteristics are:

  • Awareness (site A: 2.41/ site B: 2.3).
  • Salience (site A: 2.28/ site B: 2.23).
  • Credibility (site A: 3.51/ site B: 3.78).
  • Control (site A: 2.91/ site B: 3.05).
  • Fairness (site A: 2.99/ site B: 3.12).
  • Unintended (site A: 2.4/ site B: 2.13).
  • Feedback (site A: 2.89/ site B: 2.76).
  • Impact (site A: 2.55/ site B: 2.38).

There were 560 respondents.

Slide 7

Telephone Interviews with Physician Practice Leaders

  • Importance of dollars.
  • Complexity of distribution formulas.
  • Clinical relevance of quality targets.
  • Validity of data.
  • Role of individual physicians (physician-centered vs. system-oriented).

Slide 8


  • Physician attitudes may differ from public commentary.
  • Providers appear confused about administration of programs.
  • Providers are comfortable with clinical relevance of quality targets but are not impressed with the associated dollars.

Current as of March 2005

Internet Citation:

Evaluation of the Rewarding Results Program. Text version of a slide presentation at a Web conference. Agency for Healthcare Research and Quality, Rockville, MD.

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