A group of researchers tested the theory that paying doctors for performance would improve healthcare quality and discovered that in one of the most ambitious projects, most of the pay-for-performance money already goes to the best doctors, with only marginal gains in quality to show for the money. The number of health plans that have adopted P4P plans has been growing rapidly, notes Harvard School of Public Health Assistant Professor of Health Economics and Policy Meredith B. Rosenthal, the lead author of the study that appeared in the October 12 issue of the Journal of the American Medical Association. But they're making the adoption of the plans a leap of faith, believing they will spur quality improvements without any data to back up their assumptions. One of the biggest to act was PacifiCare Health Systems, which two years ago started handing out bonuses to its California medical groups based on meeting or exceeding 10 clinical and service quality targets — all data that consumers have had access to since 1998. That same data is gathered on 42 medical groups in the Pacific Northwest that work with PacifiCare, but didn't get bonuses. Comparing the bonus groups with non-bonus groups, researchers found that the lowest medical groups on the quality totem pole improved the most, but the groups that were already at or ahead of the baseline improved the least — but snared 75 percent of the bonus money that was available. Their conclusion: "Paying clinicians to reach a common, fixed performance target may produce little gain in quality for the money spent and will largely reward those with higher performance at baseline." Why the lack of results? Maybe because the bonuses weren't big enough to capture anyone's attention. The maximum annual bonus available per member was $27, 5 percent of the capitation amount. And PacifiCare payments overall only accounted for 15 percent of average revenue. And maybe because it takes more time to have an effect. "To alter the underlying rate of improvement, physician groups may need to make investments in infrastructure and human resources, and these investments may be staged to take advantage of the cash flow from several quarters of bonus payments." But don't look for anyone to back away from P4P plans anytime soon. Pay-for-performance plans for hospitals have included sizable rewards and registered solid improvements in care. Soon after the Harvard study was released, the Centers for Medicare and Medicaid Service announced that the first-year results for an $8.85 million project to pay top-performing hospitals a bonus reaped sizeable gains in quality. Looking at 33 quality indicators at 260 hospitals, said CMS, they found average gains in each indicator of 6.6 percent over the year they provided bonuses. The lives of about 235 heart attack patients were saved as a result of the improvement in quality for that one indicator alone. "The ultimate goal of the (plan) is to determine whether pay-for-performance impacts the quality of care in our nation's hospitals," said Richard Norling, president and chief executive officer of Premier Inc, which is managing the project for CMS. "Findings from the first year of this project clearly indicate that it does." Michigan Blues has been touted as a leading example of pursuing a pay-for-performance plan for hospitals that has reaped real improvements in the quality of care. Some standards of care that improved: · Rates of patients receiving aspirin upon arrival were 95 percent at incentive hospitals, compared with 91 percent nationally and 90 percent for non-incentive hospitals. · Patients receiving beta blockers upon arrival were 93 percent compared with 83 percent nationally and 80 percent non-incentive. · Patients prescribed beta blockers at discharge were 96 percent compared with 84 percent nationally and 80 percent for non-incentive. Patients receiving a left ventricular function assessment (a determiner of blood flow through the heart) were 93 percent compared with 78 percent nationally and 75 percent at non- incentive hospitals. · Patients prescribed ACE inhibitors at discharge were 82 percent compared with 74 percent nationally and 67 percent at non-incentive hospitals. But Meredith's group says that from what they can see, P4P for doctors on the health plan level remains distinctly a work in progress.