University of Minnesota Medical School, Twin Cities Campus, Minneapolis, MN, USA.
University of Minnesota, Department of Family Medicine and Community Health, 420 Delaware St SE, Minneapolis, MN 55455, USA.
Prev Med. 2022 Nov;164:107274. doi: 10.1016/j.ypmed.2022.107274. Epub 2022 Sep 23.
As American healthcare shifts to value-based payment, Pay-for-Performance (P4P) has become an important and controversial topic. One of the main controversies pertains to its potential to narrow or widen existing healthcare disparities depending on how the program is designed and implemented. It is thus imperative to understand which design features are most likely to reduce disparities. We conducted a systematic literature review from 2004 to 2021 of P4P's impact on disparities. Given the interdisciplinary nature of P4P research, multiple search strategies were combined, and many study designs were eligible for analysis. The literature was then qualitatively analyzed, with themes and major findings developed using Grounded Theory. Six major design features emerged as most promising in leveraging P4P to reduce disparities: 1) Risk/Case-Mix Adjustment; 2) Stratified Performance Measures/Stratification; 3) Disparity Reduction Metrics; 4) Exception Reporting; 5) Pay-for-Improvement; and 6) Population-Specific Metrics. Each design feature has its own mechanism, strengths, and weaknesses. We identify and define these features' direct and indirect effects on healthcare disparities. The interaction of each design feature with one another, with P4P as a whole, and within the larger reimbursement system can have considerable effects on disparities. Promising strategies exist to leverage P4P to narrow disparities for clinically and socially complex patients. The six design features discussed in this review help P4P programs address structural disadvantages faced by such patients and their providers. In regard to health equity, these design features can transform P4P from being part of the problem to being part of the solution.
随着美国医疗保健向基于价值的支付模式转变，按绩效付费（P4P）已成为一个重要且颇具争议的话题。其中一个主要争议点在于，其可能会根据计划的设计和实施情况，缩小或扩大现有的医疗保健差距。因此，了解哪些设计特点最有可能缩小差距是至关重要的。我们对 2004 年至 2021 年期间 P4P 对差距影响的文献进行了系统回顾。鉴于 P4P 研究的跨学科性质，我们结合了多种搜索策略，并对许多研究设计进行了分析。然后，对文献进行了定性分析，使用扎根理论开发了主题和主要发现。有六个主要的设计特点被认为最有希望利用 P4P 来缩小差距：1）风险/病例组合调整；2）分层绩效衡量标准/分层；3）减少差距衡量标准；4）例外报告；5）支付改善；6）特定人群的衡量标准。每个设计特点都有其自身的机制、优势和劣势。我们确定并定义了这些特点对医疗保健差距的直接和间接影响。每个设计特点与其他设计特点之间的相互作用、与 P4P 整体的相互作用以及在更大的报销系统中的相互作用，都会对差距产生相当大的影响。存在一些有前途的策略，可以利用 P4P 来缩小临床和社会复杂患者的差距。本文讨论的六个设计特点有助于 P4P 计划解决这些患者及其提供者所面临的结构性劣势。在健康公平方面，这些设计特点可以使 P4P 从问题的一部分转变为解决方案的一部分。
