Abstract 202: Impact Of Productivity Targets And Performance Reviews For Specialty Practices In The Veterans Health Administration

Introduction: In 2013, the Veterans Health Administration (VHA) introduced a program setting minimum physician productivity targets for specialty practices based on the ratio of total work Relative Value Units to clinical full-time equivalents. Practices with productivity below their targets were required to undergo annual reviews and submit remediation plans. We have previously demonstrated that reviewed cardiology practices experienced large increases in productivity though the contribution from regression toward the mean is unknown.

Hypothesis: We hypothesized that the introduction of the VHA’s program was associated with larger increases in productivity at low-productivity practices.

Methods: We extracted productivity metrics from fiscal year 2009-2019 reports for VHA practices in 4 specialties: cardiology, gastroenterology, neurology, and surgery. We identified low-productivity practices using VHA minimum productivity targets. We used linear regression to compare changes in productivity at these practices before and after implementation of the VHA’s program, controlling for specialty and facility level effects.

Results: Of 4,249 specialty practice-years, we identified 383 as low productivity. Prior to implementation of the VHA’s program, there was evidence of regression toward the mean with relative increases in productivity ranging from 21% for surgery to 27% for cardiology the year after a practice was designated as low productivity. After implementation of the VHA’s program, there was evidence of an independent program effect with an additional relative annual productivity increase of 3.0% (95% CI 1.1 to 4.9%) at these practices. There was no evidence of effect modification for cardiology practices.

Conclusions: A majority of the increase in productivity observed at low-productivity VHA specialty practices appears to be due to regression toward the mean, with a smaller but significant contribution from the VHA’s productivity program. Policies incentivizing productivity of specialist physicians at the group level may be an effective way to increase care efficiency in integrated healthcare systems. Evaluations of programs targeting low-performing practices should be designed to account for regression toward the mean.