Volume 48 | Number 4 | August 2013

Abstract List

Rachel M. Werner M.D., Ph.D., R. Tamara Konetzka Ph.D., Daniel Polsky


Pay‐for‐performance (P4P) is commonly used to improve health care quality in the nited tates and is expected to be frequently implemented under the ffordable are ct. However, evidence supporting its use is mixed with few large‐scale, rigorous evaluations of P4P. This study tests the effect of P4P on quality of care in a large‐scale setting—the implementation of P4P for nursing homes by state edicaid agencies.

Data Sources/Study Setting

2001–2009 nursing home Minimum Data Set and Online Survey, Certification, and Reporting () datasets.

Study Design

Between 2001 and 2009, eight state edicaid agencies adopted P4P programs in nursing homes. We use a difference‐in‐differences approach to test for changes in nursing home quality under P4P, taking advantage of the variation in timing of implementation across these eight states and using nursing homes in the 42 non‐P4P states plus ashington, as contemporaneous controls.

Principal Findings

Quality improvement under P4P was inconsistent. While three clinical quality measures (the percent of residents being physically restrained, in moderate to severe pain, and developed pressure sores) improved with the implementation of P4P in states with P4P compared with states without P4P, other targeted quality measures either did not change or worsened. Of the two structural measures of quality that were tied to payment (total number of deficiencies and nurse staffing) deficiency rates worsened slightly under P4P while staffing levels did not change.


Medicaid‐based P4P in nursing homes did not result in consistent improvements in nursing home quality. Expectations for improvement in nursing home care under P4P should be tempered.