Patient Outcomes Improved by Pay-For-Performance

Pay incentives for clinician performance can improve cardiovascular care in small primary care clinics that use electronic health records, a new study reports.

Management of chronic diseases, such as diabetes and heart disease, is important in improving patient health and reducing health care costs. One new health care model is pay-for-performance (P4P), which provides financial incentives to clinicians for achieving better health outcomes. In the traditional “fee for service” model, doctors are paid a set amount regardless of patient outcomes.

A team led by Drs. Naomi S. Bardach and R. Adams Dudley from the University of California, San Francisco, in conjunction with researchers from the New York City Department of Health and Mental Hygiene, examined the effects of P4P in small primary care clinics (1-10 clinicians). The 84 participating clinics were located in New York City and used electronic health records software as part of a city program.

Participating clinics were grouped by size and location and randomized to incentive or control (usual care). There were an average of about 4,500 patients in the intervention group clinics and 3,000 in control group clinics. At least 10% of the patients were on Medicaid or were uninsured.

The study was funded in part by NIH’s Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), National Center for Research Resources (NCRR), and National Center for Advancing Translational Sciences (NCATS). The findings were published on September 11, 2013, in the Journal of the American Medical Association.

There were 4 key quality goals. All are known to reduce long-term cardiovascular risk: aspirin or antithrombotic medication prescription, blood pressure control, cholesterol control, and smoking cessation interventions. For the P4P clinics, a financial incentive was paid to physicians when a patient met a quality goal. Incentives were tiered; higher payments were given when patients who were sicker, or who had Medicaid or were uninsured, met goals. Maximum payments were $200 per patient and $100,000 per clinic. The effects were assessed from April 2009 through March 2010.

Performance improved in both groups of clinics over the course of the study. Clinics with the incentive plan demonstrated significantly greater improvements than control clinics in rates of appropriate antithrombotic prescription (12% vs. 6.1%) and rates of smoking cessation interventions (12.4% vs. 7.7%).

The incentivized clinics also showed improvements in blood pressure control in patients with hypertension (9.7% vs. 4.3%) and in patients with hypertension plus diabetes or vascular disease (9.5% vs. 1.7%). Incentivized clinics performed better on most measures for Medicaid and uninsured patients, but these effects weren’t great enough to prove they weren’t due to chance.

“Pay-for-performance programs shift the focus from basic care delivery to high-quality care delivery, so they are designed to incentivize people to improve care,” Bardach says. “The numbers are meaningful because the rates of blood pressure control were low to begin with, so an improvement of even 5% of patients is relatively quite large. This is a high-risk population for heart attack and stroke, so getting their blood pressure under control will make a difference.”

The researchers note that since the goal of the P4P program is to improve long-term outcomes, it will be important to assess the impact over a longer time period.

— by Carol Torgan, Ph.D.