What Is The Difference Between Pay for Performance and Accountable Care Organizations

Where's that evidence?

The Disease Management Care Blog has occasionally wondered about the difference between pay for performance (P4P) and accountable care organizations (ACOs).  While the latter involves a more explicit transfer of risk, it thinks the underlying logic for both is ultimately the same: better quality performance should translate into less sickness, fewer specialist physician visits and reduced hospitalizations which, in turn, should save money that can be shared with the providers.  Assuming that's true, the possibility of getting that kind of money should prompt physicians to prevent, coordinate, counsel, immunize and screen instead of treat, refer, ignore, not immunize and hustle out the door.

Unfortunately, a recently published Cochrane Review says otherwise. 

The DMCB likes CRs because they are state-of-the-art and highly disciplined reviews of the world's scientific medical literature.  In this instance, after an exhaustive examination of every published paper on the topic of P4P, the authors conclude....

"....there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care."

The DMCB will be the first to argue that academic, rigorously conducted, randomized and controlled clinical trials are not the final answer when it comes to managing the subtle complexities of physician behavior change.  The DMCB has run into some very smart and passionate physician leaders who have few doubts about the real world links between P4P, increased quality and reduced cost.

That being said, given the commonalities between P4P and ACOs, no one should assume that ACOs are going to succeed based on any notions of "evidence" that the promise of savings will translate into a changed physician workforce.   Cochrane says it just ain't there.