Study says no evidence pay-for-performance improves outcomes

A new study calls into question pay-for-performance's impact on patient outcomes.

As physicians who treat Medicare patients gear up for MACRA, a new study has some troubling findings: Pay-for-performance models do not improve health outcomes.

Researchers, who did a systematic literature review, found pay-for-performance programs may be associated with improved processes of care in ambulatory settings, but that there’s no demonstration they have consistently improved health outcomes in any outpatient or inpatient setting, according to the study published in the Annals of Internal Medicine.

Pay-for-performance is the model behind the new Medicare reimbursement system under the Medicare Access and CHIP Reauthorization Act (MACRA), which just began on Jan. 1.


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The researchers looked at 69 studies published from June 2007 to October 2016 and found no clear evidence that the pay incentives made a difference in changing health outcomes. The researchers said it is not clear whether the findings suggest that it is unlikely pay-for-performance models will have large effects or if the failure is related to “marked differences in program design, patient population, and incentive target.”

The findings are troubling given that 600,000 clinicians are now subject to MACRA’s financial incentives for high-quality, high-value care, writes Teryl K. Nuckols, M.D., of the Cedars-Sinai Medical Center in Los Angeles, in an accompanying editorial. Under MACRA’s Merit-Based Incentive Payment System (MIPS) the government will assign penalties or rewards to clinicians, making it both national policy and the largest pay-for-performance initiative in history, he says.

MACRA establishes a complex new Medicare payment system. MIPS penalties and bonuses start at 4% in 2017 and will grow to 9% in 2022, with additional money given to exceptionally performing clinicians. 

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