Evidence Gap in Pay-for-Performance Plan Assessment Could Worsen Gender Inequalities

The consideration of sex and gender in studies evaluating pay-for-performance plans for family physicians is inadequate, warns an analysis published in the journal Human Resources for Health. 

“There is a dearth of evidence on gender-based outcomes of publicly funded incentivizing physician payment schemes for chronic disease care,” wrote researchers from the University of New Brunswick, Canada. “As the popularity of pay-for-performance to achieve health system goals continues to grow, so does the risk of unintended consequences.” 

Researchers conducted a gender-based analysis of 39 studies of eight pay-for-performance interventions spanning seven countries. The systematic review focused on pay-for-performance plans for patients with diabetes.  

According to the study, evidence supports biological and psychosocial differences in the progression of diabetes and complications in men and women. Consequently, a move toward health financing of “population needs” that fails to consider patient gender could worsen outcomes. Additionally, with female physicians earning less than male physicians, researchers also wondered if incentive reimbursements would reflect or exacerbate existing payment inequalities.  

On the patient side, only 28% of studies assessing pay-for-performance models reported sex-disaggregated patient data on outcomes, and only 8% substantively discussed results, researchers reported. None of the studies evaluated the interaction of patient sex with the intervention. 

On the provider side, just 15% of studies controlled statistically for the sex of the clinician. None discussed the effect of the pay-for-performance model on gender equity in providers’ work lives. 

“In other words,” researchers wrote, “we were unable to answer our original research questions as to whether pay-for-performance contributes to gender equity in patient and provider outcomes due to a lack of comprehensive consideration of the issue in the available literature,” researchers write. “This finding highlights a critical evidence gap to support physician workforce financing policy decisions that may lead to unintentionally aggravated pre-existing gender inequalities.” 

—Jolynn Tumolo

Reference 

Gupta N, Ayles HM. The evidence gap on gendered impacts of performance-based financing among family physicians for chronic disease care: a systematic review reanalysis in contexts of single-payer universal coverage. Hum Resour Health. 2020;18(1):69. Published 2020 Sep 22. doi:10.1186/s12960-020-00512-9