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Multicenter Study
. 2010 May 11:340:c1898.
doi: 10.1136/bmj.c1898.

The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanente indicators

Helen Lester  1 , Julie Schmittdiel, Joe Selby, Bruce Fireman, Stephen Campbell, Janelle Lee, Alan Whippy, Philip Madvig
Affiliations
Multicenter Study

The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanente indicators

Helen Lester et al. BMJ. .

Abstract

Objective: To evaluate the effect of financial incentives on four clinical quality indicators common to pay for performance plans in the United Kingdom and at Kaiser Permanente in California.

Design: Longitudinal analysis.

Setting: 35 medical facilities of Kaiser Permanente Northern California, 1997-2007.

Participants: 2 523 659 adult members of Kaiser Permanente Northern California. Main outcomes measures Yearly assessment of patient level glycaemic control (HbA(1c) <8%), screening for diabetic retinopathy, control of hypertension (systolic blood pressure <140 mm Hg), and screening for cervical cancer.

Results: Incentives for two indicators-screening for diabetic retinopathy and for cervical cancer-were removed during the study period. During the five consecutive years when financial incentives were attached to screening for diabetic retinopathy (1999-2003), the rate rose from 84.9% to 88.1%. This was followed by four years without incentives when the rate fell year on year to 80.5%. During the two initial years when financial incentives were attached to cervical cancer screening (1999-2000), the screening rate rose slightly, from 77.4% to 78.0%. During the next five years when financial incentives were removed, screening rates fell year on year to 74.3%. Incentives were then reattached for two years (2006-7) and screening rates began to increase. Across the 35 facilities, the removal of incentives was associated with a decrease in performance of about 3% per year on average for screening for diabetic retinopathy and about 1.6% per year for cervical cancer screening.

Conclusion: Policy makers and clinicians should be aware that removing facility directed financial incentives from clinical indicators may mean that performance levels decline.

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Conflict of interest statement

Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that all authors had: (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) HL and SC are contracted to the National Institute for Health and Clinical Excellence to provide advice on removal of indicators and pilot new indicators for the Quality and Outcomes Framework. The views expressed are those of the authors and do not necessarily represent the views of NICE or its independent Quality and Outcomes Framework advisory committee.

Figures

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Fig 1 Control of hypertension (systolic blood pressure <140 mm Hg) in relation to financial incentives in adults aged ≥20 (data only available from 2002)
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Fig 2 Glycaemic control (<8%) in relation to financial incentives in adults aged 18-75
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Fig 3 Percentage of adults aged ≥31 screened for diabetic retinopathy in relation to financial incentives
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Fig 4 Percentage of women aged 21-64 screened for cervical cancer in relation to financial incentives
See this image and copyright information in PMC

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