Impact of a pay for performance program to improve diabetes care in the safety net

ObjectiveTo evaluate the impact of a “piece-rate” pay for performance (P4P) program aimed at improving diabetes care processes, outcomes and related healthcare utilization for patients enrolled in a not-for-profit Medicaid-focused managed care plan.MethodsTo evaluate Hudson Health Plan's P4P program in New York (2003–2007), we conducted: (1) a case-comparison difference-in-difference study using plan-level administrative data; (2) a patient-level claims data analysis; and (3) a cross-sectional survey.ResultsThe case-comparison study found that diabetes care processes (e.g., HbA1c, lipid, and dilated eye exam rates) and outcomes (e.g., LDL-C < 100 mg/dL) did not improve significantly over the study period. Claims analysis showed that younger adults had significantly increased odds (OR 3.50–3.56, p < 0.001) of using emergency and hospital-based services and similarly decreased odds of receiving recommended care process (OR 0.22–0.36, p < 0.01–0.001). Survey study indicated that practices lack fundamental quality improvement infrastructures and training.ConclusionsRecent health legislation mandates the use of P4P incentives in government programs that disproportionately care for patients with lower socioeconomic or minority backgrounds (e.g., Medicaid, Veterans Health Administration, and Tricare). More research is needed in order to understand how to tailor P4P programs for vulnerable care settings.

► Pay for performance efforts may need to be tailored to underserved settings.
► A state-of-the-art pay for performance program did not improve diabetes care.
► Participating practices lacked fundamental QI infrastructures and training.
► Young adults (18-30 years) were least likely to receive recommended care.