Effectiveness of pay-for-performance in primary care: the Portuguese experience

Abstract

Background The benefits of pay-for-performance (P4P) in primary care (PC) are not consensual. We evaluated the impact of the P4P Portuguese model on quality of care and expenditures. Methods The data included the outcomes for the 12 performance indicators at 966 public PC units followed between 2009 and 2013 (n = 57,960). The indicators referred to care for children and newborns, management of diabetes and hypertension, and cancer screening (quality); and to drugs/exams expenditures. We compared the evolution of indicators between PC units rewarded by individual incentives to physicians (treatment group), units rewarded by team incentives only (control group I), and units without P4P payment (control group II). Generalized estimating equations were used to estimate differences-indifferences models, using the first year of P4P as proxy of the pre-P4P situation. Results The PC units in the treatment group performed significantly better for all indicators in the first year. Though, the rate of quality improvement was significantly greater at control group I for seven out of the ten quality indicators, while no significant differences were observed in the remaining three. Also, the rate of improvement was significantly greater at control group II for three quality indicators, while no significant differences were observed in five of them. In contrast, the reduction of health expenditures was always significantly more pronounced in the treatment group. Conclusions The P4P with individual incentives was associated to an initial quality advantage, which however reduced across time; in contrast, the gap accentuated in regard to their initially lower expenditures. The short-term quality gains confirm previous evidence on the P4P effectiveness. On the one hand, ceiling effects may have limited the improvement at fully incentivized units. On the other hand, the public display of performance may have enhanced the quality at units excluded from the P4P. Key messages The Portuguese experience shows that the pay-for-performance in primary care is effective in improving the quality of care and reducing expenditures The improvements related to the pay-for-performance were however limited to the short term, confirming previous evidence