Popular pay-for-performance schemes that reward physicians for how well their patients comply with preventive medicine programs could hurt the pocketbooks of doctors serving neighborhoods with greater numbers of the poor, blacks, Hispanics and foreigners, according to a RAND Corporation study published in Health Affairs on Tuesday.

A simulation run by RAND based on data from Massachusetts suggests a typical practice serving catchments with higher numbers of the poor and ethnic minorities could earn up to $7,000 less a year under a competitive rewards scheme, possibly further driving away qualified doctors from such neighborhoods.

"These results substantiate the concern that the distribution of performance-based payments may widen sociodemographic disparities in health care resources, potentially exacerbating existing disparities in the quality of care," write the study's authors.

For the study, the researchers at the Santa Monica, Calif.-based think tank checked census data from Massachusetts to determine the socioeconomic makeup of neighborhoods. They also gathered health claims from 2007 on procedures submitted to health plans from close to 500 small, multi-person practices in the state.

They then ran a simulation partly based on a Medicare incentive program, called the Medicare Care Management Performance demonstration, to see what payouts the doctors would get under a competitive rewards scheme that ranks physician practices and pays them for how many of their patients undergo certain routine preventive screenings for cancer or, if they have diabetes, get appropriate tests.

They found that practices in communities with higher percentages of blacks, Hispanics and the poor, or which were classified as community health centers, could earn dramatically less through such a pay-for-performance program. The biggest disparity was seen between those practices that served populations with higher numbers of poor people versus those in richer areas, with doctors in communities that had twice the percentage of unemployed or people living on public assistance getting a median $2,600 per practice through such a program. Doctors' offices in richer areas could get a median additional $9,700 per practice through the rewards schemes.

COMPETITIVE SCHEMES EXAGGERATE DIFFERENCES

The differences in payment were in many cases larger than the differences in quality measured by the payment scheme, which tended to be modest. Only for compliance on colorectal screening, breast and cervical cancer exams, and eye exams for diabetes were there really significant differences between the groups, and they were often small, with compliance on colorectal screening showing the biggest gap. Performance scores were around nine percentage points lower among practices that serve areas with more blacks, Hispanics and non-U.S. citizens.

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