P4P and moderated effects on smoking cessation support in primary care practices

Background/Objective: While financial incentives to improve the quality of preventive care have typically focused on rewarding relatively simple clinical services such as immunizations and screenings, less is known about their effect on more complex interventions such as behavior or lifestyle modification. Additionally, questions remain about the role that organizational structures play in moderating the effect of pay for performance (P4P). This study examines P4P programs that targeted smoking cessation as a priority area in primary care practices. Associations between P4P and cessation support, as well as interactive effects of organizational structures and clinical systems are described.

Methods: This study used data collected from 102 primary care practices participating in a national RWJF initiative. Cross-sectional data on general organizational characteristics, public reporting, clinical systems/structures, and cessation support were analyzed. Ordinal regression was used to estimate the practice's level of support for smoking cessation, as well as the interactive effects of P4P with various organizational and clinical features. Categories of increasing support for cessation ranged from distributing informative pamphlets, to involving health educators who were affiliated with the practice, saw patients on referral, and were trained in patient empowerment and problem-solving methodologies.

Results: Practices that participated in P4P smoking programs were more likely to offer higher levels of support for cessation (p<0.01). Practice size, ownership, specialty type, and health risk assessment for tobacco use did not significantly modify the effect of P4P. Affiliation with payers or organizations (e.g., health plans, large employers) that publicly reported practice-level performance information negatively affected the relationship between P4P and cessation support (p<0.05). Having a comprehensive registry for preventive care (e.g., with patient name, preventive care need, contact information) enhanced the positive association between incentives and support for cessation (p<0.05).

Conclusion: P4P may positively impact more complex interventions for health promotion and behavior change. Clinical systems such as registries that proactively facilitate preventive care and patient follow-up strengthened P4P's effect, while more basic tools such as health risk assessment did not. Contrary to expectation, public reporting of performance information significantly attenuated the relationship between P4P and cessation support.

Policy implications: Direct incentives may be effective in supporting smoking cessation in primary care practices. Coordinating with clinical systems that facilitate prevention can magnify the effect of P4P, and financial incentives may likewise add value to existing clinical systems.