Study says P4P programs may unfairly penalize some hospitals

The study suggests that pay-for-performance systems may penalize hospitals that care for patients who are at a socioeconomic disadvantage, and compares hospital rankings on standard process measures for heart attack care to determine whether patient case mix varied with performance, and would potentially alter hospitals' eligibility for financial incentives in a pay-for-performance program. Process performance metrics generally do not account for a hospital's patient demographics, clinical characteristics and mix of treatment opportunities. "Case-mix adjustment would make it more likely that these hospitals caring for underserved patients would qualify for incentive payments, less likely be penalized, or both," the authors state.


JAMA Article:: Association of Patient Case-Mix Adjustment, Hospital Process Performance Rankings, and Eligibility for Financial Incentives


While most comparisons of hospital outcomes adjust for patient characteristics, process performance comparisons typically do not.


To evaluate the degree to which hospital process performance ratings and eligibility for financial incentives are altered after accounting for hospitals' patient demographics, clinical characteristics, and mix of treatment opportunities.

Design, Setting, and Patients

Using data from the American Heart Association's Get With the Guidelines program between January 2, 2000, and March 28, 2008, we analyzed hospital process performance based on the Centers for Medicare & Medicaid Services' defined core measures for acute myocardial infarction. Hospitals were initially ranked based on crude composite process performance and then ranked again after accounting for hospitals' patient demographics, clinical characteristics, and eligibility for measures using a hierarchical model. We then compared differences in hospital performance rankings and pay-for-performance financial incentive categories (top 20%, middle 60%, and bottom 20% institutions).

Main Outcome Measures

Hospital process performance ranking and pay-for-performance financial incentive categories.


A total of 148 472 acute myocardial infarction patients met the study criteria from 449 centers. Hospitals for which crude composite acute myocardial infarction performance was in the bottom quintile (n = 89) were smaller nonacademic institutions that treated a higher percentage of patients from racial or ethnic minority groups and also patients with greater comorbidities than hospitals ranked in the top quintile (n = 90). Although there was overall agreement on hospital rankings based on observed vs adjusted composite scores (weighted , 0.74), individual hospital ranking changed with adjustment (median, 22 ranks; range, 0-214; interquartile range, 9-40). Additionally, 16.5% of institutions (n = 74) changed pay-for-performance financial status categories after accounting for patient and treatment opportunity mix.


Our findings suggest that accounting for hospital differences in patient characteristics and treatment opportunities is associated with modest changes in hospital performance rankings and eligibility for financial benefits in pay-for-performance programs for treatment of myocardial infarction.


Author Affiliations: Duke Clinical Research Institute and Duke University Medical Center, Durham, North Carolina (Drs Mehta, Liang, Hernandez, and Peterson, and Ms Karve); Denver Veterans Affairs Medical Center, Denver, Colorado (Dr Rumsfeld); and University of California Los Angeles Medical Center, Los Angeles (Dr Fonarow).

Authors: Rajendra H. Mehta, MD, MS; Li Liang, PhD; Amrita M. Karve, BA; Adrian F. Hernandez, MD, MHS; John S. Rumsfeld, MD, PhD; Gregg C. Fonarow, MD; Eric D. Peterson, MD, MPH


(SOURCES: Advisory Board Daily Briefing,, October 23, 2008; Journal of the American Medical Association, JAMA. 2008;300(16):1897-1903,, accessed October 26, 2008)