Qualitative insights into how pediatric pay-for-performance programs are being designed

Pediatric pay-for-performance (P4P) programs are proliferating, and little is known about them. The goal of this study is to better understand how these programs began, and how they are designed and implemented from the perspectives of those with experience running pediatric P4P programs.

Cross-sectional semistructured interviews with named program directors and key supporting staff from 11 of 17 publicly described pediatric P4P programs that have been in operation for at least 1 year (commercial and Medicaid sponsored) regarding their program's beginning, design, top challenges and recommendations, impact, and considerations regarding the needs of children with chronic health conditions.

Eleven programs have allocated approximately $221 million toward pediatric P4P efforts by means of both bonus and penalty incentives, potentially affecting 4.3 million children. They struggle with involving pediatricians, desiring more vetted pediatric performance measures and strategies for generally dealing with small sample sizes, and targeting the quality of care delivered to children with chronic health conditions, but they generally view these efforts to be effective.

Those with experience running these early pediatric P4P programs show that pediatricians have not necessarily been involved in program design, face basic uncertainties of P4P program design, and generally do not target the care provided to children with chronic health conditions. They desire greater input from physicians who care for children and vetted pediatric measures, and they need help facing methodological challenges, such as small sample size and risk adjustment.