Congressional Newsletter
Monthly updates to Congress on RAND's work in health policy

Pay-for-Performance Programs May Worsen Disparities in Primary Care

African-American woman in doctor's office

Pay-for-performance programs are an increasingly popular strategy for improving the quality of medical care. Under such programs, physician groups may receive bonus payments if they provide recommended care, such as periodic blood tests for patients with diabetes. However, rewarding primary care physicians for providing better care could widen disparities between the quality of care received by patients in medically underserved communities and that received by patients living in more advantaged communities.

A team of RAND researchers simulated the impact of a pay-for-performance program used in a current Medicare demonstration project on physician practices that serve higher and lower shares of patients from medically vulnerable communities in Massachusetts. A total of 438 primary care practices were included in the study, which used performance information from 2007.

The analysis found that, under the simulated pay-for-performance program, medical practices that serve vulnerable populations would receive about $7,100 less annually than other practices because of existing disparities in the quality of health care. This finding suggests that pay-for-performance programs could have the unintended effect of diverting resources away from medically needy communities, potentially further widening gaps in the quality of primary care. Addressing this issue may require structuring pay-for-performance programs to account for payment shortfalls that could worsen medical disparities. The researchers suggest that one approach might be to target grants to physicians who care for vulnerable populations, which could offset resource disparities while preserving the incentive to improve the quality of care for all patients.

READ MORE: Performance-Based Payments for Primary Care Providers May Worsen Disparities in Medical Care

Upcoming Briefing

On August 9, Brian Stecher will be moderating a panel discussion on "Improving Performance Based Accountability for Public Service" that discusses pay-for-performance across several disciplines, including health-related pay-for-performance programs. Mark your calendar and watch your inbox for more information as the briefing date approaches.

Food Allergies: Clearer Definitions and More Reliable Tests Are Needed

woman grimaces over soup

Food allergies are a growing concern. In addition to threatening health and well-being, food allergies can reduce the quality of people's lives, especially for children, whose socialization and school performance may suffer. Food allergies can also be costly because they may require expensive dietary restrictions and food substitutions. Because of this potentially far-reaching impact, it is vital that clinicians agree on what constitutes a food allergy and that allergy tests be reliable.

The National Institute of Allergy and Infectious Diseases is developing clinical practice guidelines for diagnosing and managing food allergies. In support of this effort, researchers at the Southern California Evidence-Based Practice Center housed at RAND, in collaboration with colleagues at Stanford University, the Palo Alto VA Medical Center, and UCLA, reviewed evidence on the prevalence, diagnosis, and treatment of food allergies. The researchers identified more than 12,000 original studies on the topic. The central finding of their review was that the tests used to diagnose food allergies are highly unreliable, resulting in both overdiagnosis and missed diagnosis. As a result, prevalence figures (estimated by one large U.S. study to have risen from 3.3 percent to 3.9 percent between 1997 and 2007) are also shaky. At the same time, some studies identified promising new methods for managing difficult allergies, such as sensitivity to peanuts. The researchers concluded that progress in developing better management strategies would benefit from more widely accepted definitions of what constitutes a food allergy and from evidence-based diagnostic guidelines.

READ THE RESEARCH BRIEF: Diagnosing and Treating Food Allergies: The State of the Research

In California, Few Parents of Children with Special Health Care Needs Are Making Use of Paid Family Leave Benefits

father tends to sick boy

About 15 percent of children in the United States are chronically ill. These children with special health care needs (CSHCN) account for half of all child hospital days, require many more medical visits than other children, and miss many more days of school. Parents of these children face special challenges in attempting to balance work with the needs of their sick children. To help these parents, the federal government and several states have considered offering paid leave to care for ill children. California was the first state to adopt a paid family leave program: the Paid Family Leave Insurance (PFLI) program, created in 2004. (New Jersey and Washington State implemented similar programs in 2009.) California's program provides up to six weeks a year of non-job-protected leave for most employees at 55 percent of salary, up to a maximum weekly benefit of $987 in 2010. Has the program helped parents and their special-needs children?

To address this question, a team of RAND researchers surveyed a group of California parents of CSHCN about their knowledge and use of PFLI. Results showed that only 18 percent of employed parents knew about program, only 5 percent had used it, and 40 percent expressed an unmet need for leave. Beyond lack of awareness, barriers to using the benefits included parents' fear of losing their jobs and the low amount of pay provided by the leave policy. The researchers observed that future paid leave programs would benefit from job protection and more effective dissemination of program information among employees.

READ THE RESEARCH BRIEF: Perceived Effects of Paid Family Leave Among Parents of Children with Special Health Care Needs: California's Experience


Paul G. Shekelle

Paul G. Shekelle

Paul G. Shekelle, MD, PhD, is a consultant in health sciences at RAND, Professor of Medicine at the UCLA School of Medicine, and a staff physician at the VA Medical Center in West Los Angeles. His research focus has been in the application of innovative methods to the assessment and improvement of the quality of care. He spent six years as a Career Development Awardee of the VA Health Services Research and Development Service. Dr. Shekelle spent 1996-1997 in the United Kingdom as an Atlantic Fellow in Public Policy studying how quality of care was being assessed in the National Health Service. Since 1997, Dr. Shekelle has been the Director of the Southern California Evidence-Based Practice Center, and has led numerous reviews and analyses in that capacity. Dr. Shekelle also co-directed the Assessing Care of the Vulnerable Elderly project, which seeks to develop a comprehensive set of quality tools to assess care for this population.

Read more about Paul G. Shekelle »


Lindsey Kozberg
Vice President, Office of External Affairs

Shirley Ruhe
Director, Office of Congressional Relations

Kristy Anderson
Health Legislative Analyst

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