Systematic Review: Pay-for-Performance and VA Healthcare

BACKGROUND:
In 2016, there were 25.5 million Veteran appointments with non-VA providers in the community, and this number is expected to rise with the extension of the Veterans Choice Program. VA's Commission on Care recommended that payments to community providers be based on pay-for-performance (P4P) incentives. In P4P programs, a portion of payments to providers, administrators, or healthcare systems is linked to achievement of specific access to care, process of care, or patient outcome benchmarks. Investigators with VA's Evidence-based Synthesis Coordinating Center in Portland, OR sought to identify studies that examined the effects of P4P on the quality of care and health of Veterans, including potential unintended consequences, as well as program design features and implementation factors important to P4P both within VA and in the community. Investigators searched several databases (from January 2014 to March 2017) and from 1,031 studies included 30: 25 examined P4P in VA settings and 5 in community settings. In addition, they interviewed 17 key informants to better understand the program features and implementation factors that might contribute to successful P4P programs.

FINDINGS:

• Overall, evidence is insufficient to determine whether P4P results in durable improvements in the quality of healthcare in VA settings. Only 1 controlled trial and 2 observational studies examined the effectiveness of P4P on intermediate clinical outcomes (e.g., blood pressure) in Veterans.
• Interviews with key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in VA. Key informants' views on P4P in community settings included the need to: develop relationships with providers and strong-performing health systems; improve coordination by targeting documentation and data sharing processes, and troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population.
• Qualitative studies on P4P in VA found that participants felt performance measures may lead to unintended negative consequences, i.e., reduced focus on patient needs, un-incentivized areas of care, and/or healthier patient populations, and that they may negatively affect team dynamics.

IMPLICATIONS:

• Key informants recognized the potential for unintended consequences of P4P, such as overtreatment in VA settings, and suggest that implementation of P4P in the community focus on relationship building – and target areas such as documentation and coordination of care.

LIMITATIONS:

• This study was limited by the paucity of research directly assessing the effectiveness of P4P in VA settings. Studies with less-rigorous methodology, some of which had small samples, were included.
• Findings also were limited by heterogeneity in the way that P4P is implemented in VA settings.

AUTHOR/FUNDING INFORMATION:
This study was funded through HSR&D's Quality Enhancement Research Initiative (QUERI). All authors except for Drs. Mendelson and Beard are part of HSR&D's Evidence-based Synthesis Program (ESP) in Portland, OR.

Kondo K, Wyse J, Mendelson A, Beard G, Freeman M, Low A, and Kansagara D. Pay-for-Performance and Veteran Care in the VHA and the Community: A Systematic Review. Journal of General Internal Medicine. July 2018;33(7):1155-66.