Healthcare system effects of pay-for-performance for smoking status documentation

Abstract

Objectives: To evaluate the impact on smoking status documentation of a payer-sponsored pay-for-performance (P4P) incentive that targeted a minority of an integrated healthcare delivery system's patients.

Study design: Three commercial insurers simultaneously adopted P4P incentives to document smoking status of their members with 3 chronic diseases. The healthcare system responded by adding a smoking status reminder to all patients' electronic health records (EHRs). We measured change in smoking status documentation before (2008-2009) and after (2010-2011) P4P implementation by patient P4P eligibility.

Methods: The P4P-eligible patients were compared primarily with a subset of non-P4P-eligible patients who resembled P4P-eligible patients and also with all non-P4P-eligible patients. Multivariate models adjusted for patient and provider characteristics and accounted for provider-level clustering and preimplementation trends.

Results: Documentation increased from 48% of 207,471 patients before P4P to 71% of 227,574 patients after P4P. Improvement from 56% to 83% occurred among P4P-eligible patients (adjusted odds ratio [AOR], 3.6; 95% confidence interval [CI], 2.9-4.5) and from 56% to 80% among the comparable subset of non-P4P-eligible patients (AOR, 3.0; 95% CI, 2.3-3.9). The difference in improvement between groups was significant (AOR, 1.3; 95% CI, 1.1-1.4; P = .009).

Conclusions: A P4P incentive targeting a minority of a healthcare system's patients stimulated adoption of a system wide EHR reminder and improved smoking status documentation overall. Combining a P4P incentive with an EHR reminder might help healthcare systems improve treatment delivery for smokers and meet "meaningful use" standards for EHRs.

Figure 1

Patient population before (2008–2009) and after (2010–2011) pay-for-performance (P4P) implementation * Patients with ineligible visits had only a visit outside of their academic-affiliated or community-based primary care practice. CAD=coronary artery disease, DM=diabetes mellitus. Shaded boxes constitute all non-P4P-eligible patients. †These patients who had CAD, DM or hypertension and a commercial insurer who did not participate in the P4P contract were the subset of non-P4P-eligible patients who were most similar to P4P-eligible patients and were the primary comparison group in adjusted models. ‡Participating commercial insurers were three, not-for-profit insurers who contracted for P4P.

Figure 2

Unadjusted smoking status documentation by Pay-for-Performance (P4P) eligibility and year * Patients with commercial insurer that did not participate in the P4P contract and a chronic condition (diabetes mellitus, hypertension, or coronary artery disease).