NEW YORK (Reuters Health) – Pay-for-performance (P4P) programs might improve processes of care in some settings, but they do not consistently improve health outcomes in any setting, according to a systematic review.

“It’s not clear why the evidence has not shown more consistent benefit,” Dr. Devan Kansagara from Oregon Health & Science University and VA Portland Health Care System told Reuters Health by email. “One possibility is that providers are already intrinsically motivated to do the right things for their patients, which makes it harder to show the incremental benefit of a superimposed external incentive.”

P4P programs aim to improve the quality of care, reduce unnecessary use of expensive healthcare services and improve patient health outcomes by providing financial rewards or penalties according to performance on measures of quality.

Dr. Kansagara and colleagues updated and expanded a prior systematic review in order to summarize current understanding of the effects of P4P programs targeting physicians, groups, and institutions on process-of-care and patient outcomes in ambulatory and outpatient settings, both inside and outside the U.S.

They included 69 studies—58 in ambulatory settings and 11 in hospital settings—that examined a wide range of P4P programs with varying incentive structures, goals and contexts. Low-strength evidence suggested that ambulatory P4P programs might improve process-of-care outcomes over the short term, with many of the positive studies conducted in the U.K., where incentives were larger than in the U.S.

The largest process-of-care improvements occurred in areas where baseline performance was poor, the researchers report in Annals of Internal Medicine, online January 10.

P4P programs had no consistent effect on intermediate health outcomes in the ambulatory or hospital setting, although there was low-strength evidence that P4P programs might reduce hospital readmissions.

“I also think the British experience with the Quality and Outcomes Framework program is worth paying attention to,” Dr. Kansagara said. “They have had a longer and more extensive experience with pay for performance than anyone else. While they found some process of care improvements for some incentivized conditions, the overall evidence of benefit with the QOF program has been underwhelming.”

“It is interesting that, after more than a decade of experience, they have decided to scale back the number of metrics in response to provider concerns and the lack of convincing long-term evidence of benefit,” he said.

“I don’t think anyone is arguing that we should return to the days when fee-for-service reimbursement was dominant in health care,” Dr. Kansagara explained. “Value-based purchasing makes intuitive sense and may be an improvement over the historic alternative. They probably should continue to play a role in health reform; we just have to think more carefully about how they are implemented, how many metrics are in place at any given time, and how to minimize negative unintended consequences and the incremental burden placed on providers.”