Sustainability of quality improvement following removal of pay-for-performance incentives.
BACKGROUND
Although pay-for-performance (P4P) has become a central strategy for improving quality in US healthcare, questions persist about the effectiveness of these programs. A key question is whether quality improvement that occurs as a result of P4P programs is sustainable, particularly if incentives are removed.


OBJECTIVE
To investigate sustainability of performance levels following removal of performance-based incentives.


METHODS
Observational cohort study that capitalized on a P4P program within the Veterans Health Administration (VA) that included adoption and subsequent removal of performance-based incentives for selected inpatient quality measures. The study sample comprised 128 acute care VA hospitals where performance was assessed between 2004 and 2010.


METHODS
VA system managers set annual performance goals in consultation with clinical leaders, and report performance scores to medical centers on a quarterly basis. These scores inform performance-based incentives for facilities and their managers. Bonuses are distributed based on the attainment of these performance goals.


METHODS
Seven quality of care measures for acute coronary syndrome, heart failure, and pneumonia linked to performance-based incentives.


RESULTS
Significant improvements in performance were observed for six of seven quality of care measures following adoption of performance-based incentives and were maintained up to the removal of the incentive; subsequently, the observed performance levels were sustained.


CONCLUSIONS
This is a quasi-experimental study without a comparison group; causal conclusions are limited.


CONCLUSIONS
The maintenance of performance levels after removal of a performance-based incentive has implications for the implementation of Medicare's value-based purchasing initiative and other P4P programs. Additional research is needed to better understand human and system-level factors that mediate sustainability of performance-based incentives.
Center for Organization, Leadership, and Management Research (COLMR) at the VA Boston Healthcare System (152 M), 150 South Huntington Avenue, Boston, MA, 02860, USA, Justin.benzer@va.gov.
Justin K
JK
Benzer
Gary J
GJ
Young
James F
JF
Burgess
Errol
E
Baker
David C
DC
Mohr
Martin P
MP
Charns
Peter J
PJ
Kaboli
D054058:Acute Coronary Syndrome / Q000628:therapy; D006302:Health Services Research / Q000379:methods; D006333:Heart Failure / Q000628:therapy; D006787:Hospitals, Veterans / Q000191:economics / Q000592:standards; D006801:Humans; D010816:Physician Incentive Plans; D011014:Pneumonia / Q000628:therapy; D011785:Quality Assurance, Health Care / Q000379:methods; D058996:Quality Improvement / Q000191:economics*; D019984:Quality Indicators, Health Care; D012052:Reimbursement, Incentive; D014481:United States