During the five consecutive years (1999-2003) that screening for diabetic retinopathy received a bonus, screening increased from 85% to 88%; when the bonuses were dropped, though, it went to 80% in 2007.
Similarly, during the initial two years when financial incentives were attached for cervical cancer screening (1999 2000), screening rates rose slightly from 77% to 78%. During the next five years when no financial incentives were attached, rates fell to 74%. When incentives were then reattached for two more years (2006 7), screening rates increased again.
So put simply, after incentives were removed, screenings for diabetic retinopathy declined on average by about 3% per year and for cervical cancer by an average of 2% per year.
In their study, the researchers acknowledge that their study area is small. However, the questions they ask are big: what eventually happens when you remove payment incentives? Should payment incentives be used like training wheels—to get a certain clinical practice up and running and to promote quality care?
The researchers correctly note that if their findings are confirmed across a wider range of indicators, providers will need to be aware that if financial incentives are removed, their focus may change—and "they may need to think proactively about how to maintain previous levels of patient care."
But in the long run, healthcare policymakers need to think about what will happen when they remove—for whatever reason—financially incentivized clinical indicators. Rather than a blanket removal, maybe consider a stepwise reduction of payments against indicators, as the researchers suggest.
But what we need is something that has gotten very little attention when it comes to pay for performance: a good exit strategy.