Most nursing home administrators do not believe that pay-for-performance initiatives lead to improved resident care or stronger bottom lines, according to findings recently published in the Journal of Aging and Social Policy.

Investigators with the University of Pittsburgh and RAND Corp. received survey responses from more than 2,400 administrators. About two-thirds worked in states that already had instituted a pay-for-performance (P4P) program, such as the Medicare Value-Based Purchasing Demonstration. These programs reward nursing homes for meeting certain quality goals and withhold payment from poor performers.

The “most significant” finding was that very few administrators believe pay-for-performance improves care quality, the authors wrote. Dissatisfaction with the quality measures used could explain administrators’ skepticism about how well pay-for-performance can drive improvement. The statement “the right amount of quality indicators are used” garnered a summary score of only 10, on a scale in which 100 would indicate total agreement. Many respondents also did not agree that the most appropriate indicators are being used.

Very few administrators said that payment incentives are enticing. The statement that enough money is provided “to make participation worthwhile” received a summary score of only 12.

Administrators in states that already were working under pay-for-performance had a “significantly lower” opinion of the approach than administrators in other states, the researchers discovered. These administrators felt that deserving providers were being penalized and that it was hard to anticipate which facilities would earn rewards.

The findings show that pay-for-performance schemes need to be improved, the study authors concluded. Creating “report cards” could improve transparency by letting administrators see how they stack up with peer facilities, they suggested. And they proposed that cost-benefit analyses might help allay concerns about the bottom-line impacts, while aligning quality measures to initiatives like Advancing Excellence in America’s Nursing Homes could make pay-for-performance more “synergistic” with ongoing improvement efforts.