Chronic Care Improvement in Primary Care

Evaluation of an Integrated Pay-for-Performance and Practice-Based Care Coordination Program among Elderly Patients with Diabetes

Intervening in patient care through an on-site care coordinator and a pay-for-performance (P4P) program, designed to complement a third-party disease management program, did not improve care or resource usage for older diabetic adults, according to this longitudinal study.

This research looked at the effect of an intervention which included three elements: 1) a P4P program in which medical practices earned bonuses for meeting relevant quality care goals; 2) a third-party disease management call center program, staffed by nurses; and 3) a practice-based, onsite care coordinator (RN, LPN or medical assistant) who alerted doctors to ways to improve a patient's care and communicated information to the call center. The intervention was put in place for diabetic patients, age 65 or older, at nine physician-owned, primary care practices in Alabama, Tennessee and Texas. Data from claims files of 1,587 patients in the "intervention practices" were compared to data from 19,356 similar patients of practices without P4P or onsite care coordination programs; these practices did have third-party disease management programs in place. The study period was January 2004 to March 2007 but researchers were sure to include at least 24 months of preintervention data and 12 months of intervention data for each patient.

Key Findings:

  • Although researchers had hypothesized that patients with intervention would receive better care over the course of the study, care for both groups improved over time.
  • Researchers also did not see a "halo effect" in the intervention group: there was no indication that care improved beyond the incentivized indicators.
  • Regarding resource utilization, both groups were less likely to need to see a doctor over time. There were no significant differences in cost trends for the two groups.

The authors note their study does not support the notion that use of on-site care coordinator, along with P4P incentives, would improve care with a third-party disease management service. They suggest further research is needed to examine whether financial incentives were too small to have an impact or whether the role of the on-site care managers was ill-defined. The researchers do note the study underlines the facility of longitudinal analysis and importance of using comparison groups to evaluate quality improvement efforts.