Rosenthal Meredith B, Frank Richard G, Li Zhonghe, Epstein Arnold M
Department of Health Policy and Management, Harvard School of Public Health, Boston, Mass 02115, USA.
JAMA. 2005 Oct 12;294(14):1788-93. doi: 10.1001/jama.294.14.1788.
The adoption of pay-for-performance mechanisms for quality improvement is growing rapidly. Although there is intense interest in and optimism about pay-for-performance programs, there is little published research on pay-for-performance in health care.
To evaluate the impact of a prototypical physician pay-for-performance program on quality of care.
DESIGN, SETTING, AND PARTICIPANTS: We evaluated a natural experiment with pay-for-performance using administrative reports of physician group quality from a large health plan for an intervention group (California physician groups) and a contemporaneous comparison group (Pacific Northwest physician groups). Quality improvement reports were included from October 2001 through April 2004 issued to approximately 300 large physician organizations.
Three process measures of clinical quality: cervical cancer screening, mammography, and hemoglobin A1c testing.
Improvements in clinical quality scores were as follows: for cervical cancer screening, 5.3% for California vs 1.7% for Pacific Northwest; for mammography, 1.9% vs 0.2%; and for hemoglobin A1c, 2.1% vs 2.1%. Compared with physician groups in the Pacific Northwest, the California network demonstrated greater quality improvement after the pay-for-performance intervention only in cervical cancer screening (a 3.6% difference in improvement [P = .02]). In total, the plan awarded 3.4 million dollars (27% of the amount set aside) in bonus payments between July 2003 and April 2004, the first year of the program. For all 3 measures, physician groups with baseline performance at or above the performance threshold for receipt of a bonus improved the least but garnered the largest share of the bonus payments.
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.
为提高质量而采用的绩效薪酬机制正在迅速发展。尽管人们对绩效薪酬计划有着浓厚的兴趣并持乐观态度，但关于医疗保健领域绩效薪酬的已发表研究却很少。
评估一个典型的医生绩效薪酬计划对医疗质量的影响。
设计、地点和参与者：我们利用一个大型健康计划中医生群体质量的行政报告，对一个干预组（加利福尼亚州的医生群体）和一个同期对照组（太平洋西北地区的医生群体）进行了绩效薪酬的自然实验评估。纳入了2001年10月至2004年4月期间发给约300个大型医生组织的质量改进报告。
临床质量的三个过程指标：宫颈癌筛查、乳房X线摄影和糖化血红蛋白检测。
临床质量得分的改善情况如下：宫颈癌筛查方面，加利福尼亚州为5.3%，太平洋西北地区为1.7%；乳房X线摄影方面，分别为1.9%和0.2%；糖化血红蛋白方面，均为2.1%。与太平洋西北地区的医生群体相比，加利福尼亚州的网络仅在宫颈癌筛查方面，在绩效薪酬干预后显示出更大的质量改善（改善差异为3.6%[P = 0.02]）。在该计划的第一年，即2003年7月至2004年4月期间，该计划总共发放了340万美元（占预留金额的27%）的奖金。对于所有这三项指标，基线表现达到或高于获得奖金绩效阈值的医生群体改善最少，但获得的奖金份额最大。
付钱给临床医生以达到共同的、固定的绩效目标，可能在花费的金钱所带来质量提升方面收效甚微，并且在很大程度上会奖励那些基线表现较高的人。
