Pay for performance alone cannot drive quality.

OBJECTIVE To determine whether aligning design characteristics of a pay-for-performance program with objectives of an asthma improvement collaborative builds improvement capability and accelerates improvement. DESIGN Interrupted time series analysis of the impact of pay for performance on results of an asthma improvement collaborative. SETTING Forty-four pediatric practices within greater Cincinnati. PARTICIPANTS Forty-four pediatric practices with 13 380 children with asthma. INTERVENTIONS The pay-for-performance program rewarded practices for participating in the collaborative, achieving network- and practice-level performance thresholds, and building improvement capability. Pay for performance was coupled with additional improvement interventions related to the collaborative. OUTCOME MEASURES Flu shot percentage, controller medication percentage for children with persistent asthma, and written self-management plan percentage. RESULTS The pay-for-performance program provided each practice with the potential to earn a 7% fee schedule increase. Three practices earned a 2% increase, 13 earned a 4% increase, 2 earned a 5% increase, 14 earned a 6% increase, and 11 earned a 7% increase. Between October 1, 2003, and November 30, 2006, the percentage of the network asthma population receiving "perfect care" increased from 4% to 88%. The percentage of the network asthma population receiving the influenza vaccine increased from 22% to 41%, and then to 62% during the prior 3 flu seasons. CONCLUSION Linking design characteristics of a pay-for-performance program to a collaborative focused on improving care for a defined population, building improvement capability, and driving system changes at the provider level resulted in substantive and sustainable improvement.