The impact of pay-for-performance on the quality of care in ophthalmology: Empirical evidence from Germany
Introduction
Cataract surgery has become a routine surgical procedure in most developed countries. Approximately 19 million procedures are performed every year worldwide [1], of which approximately 800,000 procedures are performed in Germany [2]. According to the WHO, it is estimated that the total number of cataract procedures will rise to 32 million by the year 2020 [[1], [3], [4]]. Different approaches aim to capture the quality of care in cataract surgery. With regard to measurement of clinical reported outcomes (CROs), clinical metrics such as visual acuity and complication rates are most frequently used. Further, patient questionnaires are used in order to measure patient-reported outcome measures (PROMs) [[5], [6]]. Although there is a high number of procedures performed, research has demonstrated that quality of care in cataract surgery may differ between surgery centres and/or surgeons [[7], [8]].
Pay-for-performance (P4P) intends to solve quality deficits, or to decrease existing quality gaps, by linking payments with quality of care measurements. So far, the reimbursement schemes in German hospitals usually comprise of fixed lump-sum payment elements, but do not consider quality of care elements [9]. P4P pursues the aim of quality improvements by stimulating the extrinsic motivation of participants; that is, achieving a predefined target level and/or quality improvements may result in financial rewards, while the opposite may lead to shortfalls in remuneration. Although many studies have been carried out to assess the impact of P4P on quality of care, it remains difficult to draw firm conclusions [10]; while some studies found positive effects [[11], [12], [13]], others found no effects [[14], [15]], or even adverse effects [16]. The inconsistent evidence is mainly attributed to the limited number of studies with strong designs [10], or differences in the design of P4P reimbursement schemes [17]. Regarding the latter, the design of P4P approaches differs, especially with regard to quality-related (e.g., number of quality indicators, included patient population) and incentive-related elements (e.g., incentive structure, amount of bonus/penalty payments, payment frequency) [[17], [18]]. In this context, Ogundeji et al. showed that positive effects were three times higher for schemes with larger incentives (>5% of salary/usual budget) [19]. Regarding the incentivized quality measurements, empirical findings showed that process indicators generally led to higher improvement rates compared to outcome measures [20].
Regarding the current state of P4P in Germany, a systematic review by Veit et al. [21] found 14 different approaches across several medical fields. These were mainly implemented based on selective contracting with single health insurers, or because of quality deficits in healthcare delivery [21]. However, it still remains unclear whether any of these programs have had any impact on the quality of care. To the best of our knowledge, no rigorous evaluations have been published showing the effects of the implementation of these P4P programs. With regard to the speciality field of ophthalmology, four P4P programs from the US have been described in the literature [[22], [23], [24], [25]]; however, empirical evidence is only available for two of these approaches [[22], [23]]. As such, the first results from these programs indicate that P4P may indeed lead to both quality improvements and cost reductions [[22], [23], [26]].
Therefore, this study aims to address this research gap by evaluating whether P4P has an impact on the quality of care in Germany. In particular, our study aims to address the following two research questions: (1) Does the implementation of a comprehensive P4P reimbursement scheme have an impact on the quality of care in cataract surgery? (2) Does P4P lead to better quality of care compared with the German lump-sum payment system [9]? The following paper is divided into two parts; each part addresses one research question. In the first part of the paper, we analyse the quality of care before, during, and after the implementation of a P4P reimbursement scheme in cataract surgery. The second part contains an analysis of whether P4P leads to better quality of care results compared with the German hospital-based lump-sum remuneration scheme. As such, the quality of care of patients being treated under a P4P scheme will be compared with the quality of care of patients being treated under a lump-sum payment scheme.
Section snippets
Part 1: the impact of the implementation of P4P on the quality of care in cataract surgery
The P4P reimbursement scheme (see below) was implemented in April 2012 on the basis of an integrated care contract between a large surgical centre for ophthalmology in Northern Germany (nordBLICK Augenklinik Bellevue) and one German statutory health insurance. We conducted interrupted time series (ITS) analyses to identify whether the implementation of the P4P reimbursement scheme led to significant changes in the quality of care. Therefore, the quality of care of cataract surgery was measured
Results
Overall, 5964 cataract cases were included in the analyses, of which 1657 cases were assigned to the P4P group and 4307 cases to the control group. As shown, there were no significant differences between the study groups in terms of age, gender, type of admission and relative share of bonus and penalty payments (Table 2).
Discussion
The aim of this study was to examine whether P4P leads to significant improvements in quality of care. Our study was guided by two major questions. First, we analysed whether the implementation of a comprehensive P4P reimbursement scheme in cataract surgery had an impact on the quality of care. Second, we examined whether P4P resulted in better quality of care results compared with results that were observed under a lump-sum remuneration scheme.
In the first part of our study, we found that the
Conclusions for health policy makers
Several conclusions can be drawn from our study. First, our study provides the first empirical evidence from Germany showing that the promising proposal of P4P might not prove true. In line with the literature from the international P4P landscape, we did not find any evidence that the implementation of P4P reimbursement led to significant quality improvements. Second, the selective implementation of a P4P scheme for a certain patient group does not automatically lead to significant differences
Conflicts of interest statement
The authors declare that they have no competing interests.
Acknowledgement
none.
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