title: Pay-for-performance schemes that use patient and provider categories would reduce payment disparities.
abstract: Providers that care for disproportionate numbers of disadvantaged patients tend to perform less well than other providers on quality measures commonly used in pay-for-performance programs. This can lead to the undesired effect of redistributing resources away from providers that most need them to improve care. We present a new pay-for-performance scheme that retains the motivational aspects of standard incentive designs while avoiding undesired effects. We tested an alternative incentive payment approach that started with a standard incentive payment allocation but then "post-adjusted" provider payments using predefined patient or provider characteristics. We evaluated whether such an approach would mitigate the negative effects of redistributions of payments across provider organizations in California with disparate patient populations. The post-adjustment approach nearly doubled payments to disadvantaged provider organizations and greatly reduced payment differentials across provider organizations according to patients' income, race/ethnicity, and region. The post-adjustment of payments could be a useful supplement to paying for improvement, aligning the goals of disparity reduction and quality improvement.
authors.affiliation: Cheryl L. Damberg is the RAND Distinguished Chair in Health Care Payment Policy and a principal senior researcher in the Health Program at the RAND Corporation in Santa Monica, California.
authors.forename: Cheryl L
authors.initials: CL
authors.lastname: Damberg
authors.affiliation: Marc N. Elliott (elliott@rand.org) is the RAND Distinguished Chair in Statistics and a principal senior researcher in the Health Program at RAND in Santa Monica.
authors.forename: Marc N
authors.initials: MN
authors.lastname: Elliott
authors.affiliation: Brett A. Ewing is a statistical project associate in economics, sociology, and statistics at RAND in Santa Monica.
authors.forename: Brett A
authors.initials: BA
authors.lastname: Ewing
mesh_terms: D003953:Diagnosis-Related Groups / Q000191:economics / Q000639:trends; D005544:Forecasting; D006301:Health Services Needs and Demand / Q000191:economics / Q000639:trends; D054625:Healthcare Disparities / Q000191:economics / Q000639:trends; D006801:Humans; D007182:Income / Q000706:statistics & numerical data*; D058996:Quality Improvement / Q000191:economics*; D019984:Quality Indicators, Health Care / Q000191:economics* / Q000706:statistics & numerical data*; D011787:Quality of Health Care / Q000191:economics* / Q000639:trends*; D020444:Reimbursement, Disproportionate Share / Q000191:economics / Q000639:trends; D012052:Reimbursement, Incentive / Q000191:economics* / Q000639:trends*; D014481:United States; D035862:Vulnerable Populations / Q000706:statistics & numerical data*
keywords: Quality Of Care; health disparities; incentives; pay for performance; unintended consequences