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.