How financial incentives for physicians impact patient care
There is a growing awareness that financial incentives for physicians can have a powerful impact on the amount and type of health care provided to patients. With Obamacare, the fee-for-service payment model is associated with increased use of services that are well-reimbursed, which does not necessarily translate to attention focused on indications or quality of care.
A study, published September 11 in JAMA, found that financial incentives for physicians treating patients with hypertension (high blood pressure), resulted in greater blood pressure control. However, compared with controls, none of the financial incentives resulted in greater use of guideline-recommended medications.
“As part of the Affordable Care Act, the U.S. government has introduced pay for performance to all hospitals paid by Medicare nationwide. The New York City Health and Hospitals Corporation recently announced a performance pay plan for physicians. These and other value-based purchasing systems are intended to align incentives to promote high-quality health care. Evaluations of the effectiveness of pay-for-performance programs directed at hospitals have shown contradictory results,” according to background information for the study.
A team of researchers, including Laura A. Petersen, M.D., M.P.H., of the Veterans Affairs Medical Center and Baylor College of Medicine in Houston, conducted a randomized controlled trial to evaluate whether explicit financial incentives designed to encourage delivery of guideline-recommended care for hypertension were effective.
The trial, which was conducted at 12 outpatient clinics with 5 performance periods, enrolled 83 primary care physicians and 42 non-physician personnel, such as nurses and pharmacists, involved either: 1) physician (individual) incentives; 2) practice group incentives; 3) a combination of both; or 4) none. Participants received up to 5 payments every 4 months, and feedback reports were made available for all participants to access.
The primary outcomes measured were: 1) the number of patients (among a random sample) achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure: 2) the number of patients prescribed guideline-recommended medications: and 3) the number who developed hypotension (abnormally low blood pressure).
The 4-month performance baseline period was followed by four consecutive 4-month periods, which is when payments were made to participants based on attainment of performance goals. Participants were followed for 12 months after the performance goals ended to see if the effects were sustained.
The average total payments over the course of the study were $4,270 for the combined physician and physician practice group, $2,672 in the individual physician group, and $1,648 in the practice group.
Change in blood pressure control or appropriate response to uncontrolled blood pressure was greater only in the individual incentives group compared with the control group. The difference in change in proportion of patients achieving blood pressure control or receiving an appropriate response between the individual incentive and no incentive group was 8.36 percent.
Although the use of guideline-recommended medication increased over the course of the study, there was no change compared with controls.
The researchers also found that a significantly higher number of individual physician participants viewed their feedback reports on the website (67 percent vs. 25 percent for the control group), which suggests that such participants were aware of the relationship between performance and rewards.
“Although concerns about overtreatment have been cited in criticisms of pay-for-performance programs, we did not find a higher incidence of hypotension in the panels of physicians randomized to the incentive groups,” they write.
Even small reductions in blood pressure translate into significant reductions in morbidity and mortality, and in system-wide costs, the authors write.
“This trial addresses the needs of policy makers and payers for information about a clinically relevant payment intervention in routine practice. Payment-system interventions are attractive because of their potential scale and reach. However, payment-system interventions are only one piece of the solution to improve management of chronic diseases such as hypertension. More resource-intensive, tailored, patient-level self-management strategies may be needed to truly affect patient outcomes,” explained the study authors.
SOURCE: JAMA, Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care: A Randomized Trial, Petersen LA, Simpson K, Pietz K, et al. (doi:10.l001/jama.2013.276303)