Quality compensation programs: are they worth all the hype? A comparison of outcomes within a Medicare advantage heart failure population

J Manag Care Pharm. 2013 May;19(4):317-24. doi: 10.18553/jmcp.2013.19.4.317.


Background: Quality compensation programs (QCPs), also known as pay-for-performance programs, are becoming more common within managed care entities. QCPs are believed to yield better patient outcomes, yet the programs lack the evidence needed to support these claims. We evaluated a QCP offered to network primary care physicians (PCPs) within a Medicare managed care plan to determine if a positive correlation between outcomes and the program exists.

Objective: To compare outcomes of heart failure members under the care of PCPs enrolled in a Medicare Advantage Prescription Drug (MAPD) Plan QCP with those who are not affiliated with a QCP.

Methods: Retrospective analysis was conducted on the heart failure population of a MAPD in Texas. Heart failure members were identified using ICD-9-CM codes from inpatient and outpatient claims for 2010. These members must have been continuously eligible all 12 months of the year to be included in the analysis. The primary intervention was enrollment by the member's PCP into the QCP. Measurable outcomes included acute (hospital) admits, emergency room (ER) visits, appropriate laboratory tests, and prescriptions of medications that are evidence based and guideline driven. Centers for Medicare and Medicaid Services (CMS) risk scores and comorbidities were used to risk-adjust outcomes.

Results: A total of 4,240 members was included in the analysis. From that population, 1,225 members (28.8%) were followed by PCPs enrolled in a QCP; 3,015 members (71.1%) were followed by PCPs not enrolled in a QCP. The adjusted analysis showed that none of the drug comparisons statistically differed between the QCP and non-QCP groups, whereas all of the lab tests, including low-density lipoprotein cholesterol (LDL-C), hemoglobin A1c, creatinine, and microalbumin, as well as the acquisition of the flu vaccine, occurred more frequently in the QCP group. Acute admits and ER visits in the QCP and non-QCP groups were similar before and after adjustment. The QCP group was significantly older with a statistically significant higher prevalence of renal failure and higher CMS risk scores.

Conclusions: After evaluation of our QCP's impact on the quality of care provided to our Medicare beneficiaries, we have concluded that there is potential for health care improvement through pay-for-performance programs. We have observed in our MAPD heart failure population, enrolled in a QCP during the year of 2010, an increase in age and CMS risk scores, a decline in renal function, and noted the group to have a more female presence. Yet, the outcomes of this group (hospitalizations, ER visits, acquisition of lab tests, etc.) were similar when compared with younger, healthier members not enrolled in a QCP. We feel the clinical relevance of the data indicates that, overall, the quality of care is somewhat improved for QCP-enrolled providers when compared with non-QCP providers in regards to achieving certain quality metrics. (i.e., immunizations, HgA1c, LDL-C, etc.) Further research is definitely needed to determine if health care costs and clinical outcomes, in the long term, are improved for members enrolled in these QCP programs, as well as their impact upon a health plan's Medicare Star rating.

Publication types

  • Comparative Study

MeSH terms

  • Age Factors
  • Aged
  • Aged, 80 and over
  • Emergency Service, Hospital / economics
  • Emergency Service, Hospital / standards
  • Evidence-Based Medicine
  • Female
  • Heart Failure / economics
  • Heart Failure / therapy*
  • Hospitalization / economics
  • Hospitalization / statistics & numerical data
  • Humans
  • Insurance, Pharmaceutical Services / economics
  • Male
  • Managed Care Programs / economics
  • Managed Care Programs / organization & administration*
  • Medicare / economics
  • Medicare / organization & administration
  • Outcome Assessment, Health Care*
  • Practice Guidelines as Topic
  • Primary Health Care / economics
  • Primary Health Care / organization & administration
  • Quality of Health Care
  • Reimbursement, Incentive / economics*
  • Retrospective Studies
  • United States