Pay for Performance to Physicians Results in Better
Incentives offered a whole health care team did not
have significant effect
Sept. 17, 2013 – Just modest monetary incentive
paid to individual physicians resulted in a significant 8.36 percent
increase in patients whose blood pressure was brought down to desired
levels or who received an appropriate medical response when it was found
that their blood pressure was uncontrolled. However, incentives to a
whole health care team or to the physician plus health care team did not
have a significant effect, according to a multi-year study reported in
Journal of the American Medical Association (JAMA).
health care pundits began to suggest that pay-for-performance would
solve some of health care's woes,
Dr. Laura Petersen, professor of
medicine at Baylor College of Medicine and director of the Houston VA
Health Services Research and Development Center of Excellence, had
How do we
know that it will solve those problems? she asked. How do we know
whether or not it will create new problems? And how will we structure
these payments? As a recognized expert in the area of health care
services and quality, she set out to find the answers in a multi-year
study involving 83 physicians and 42 other health care personnel in 12
different Veterans Affairs hospital-based outpatient clinics.
her colleagues found that modest monetary incentives to individual
physicians resulted in a significant improvement in the patients
not a panacea for everything that is wrong in health care, but it can
have a significant effect in improving care," said Petersen, who is also
associate chief of staff for research at the
Michael E. DeBakey VA Medical Center.
"Pay for performance is attractive because it would be a system-wide
plan that could be implemented on a wide scale. With this, we have
demonstrated that you can implement this kind of program at 12 sites at
one time. And we were able to show a significant effect in the VA health
care system where high blood pressure is already well controlled
overall." Studies show that the baseline blood pressure control rates in
the VA system are already at 75 percent.
incentives had an important effect on physicians, she said. If the
average primary care provider has 1,000 patients, then, with incentives,
an 84 additional patients would meet hypertension goals after a year.
in the year after the incentive program ended, the effects also
diminished, which Petersen found disappointing.
thought the change would continue," she said. "It was a long
intervention and I thought people's practices would change over time.
However, it shows that the incentives were working. If their performance
had not fallen off, then we might question whether the incentives caused
the effect in the first place."
study, the clinics were assigned to one of four incentive groups:
Physician-level incentives alone; practice-level incentives; combined
incentives that included both physician incentives and practice
incentives; and a control or no incentive group. The incentives were
paid every four months for five periods. Those who took part also
received feedback reports that detailed their performance in controlling
their patients' blood pressure.
no change in the use of guideline-recommended medications among the
was documented in detailed reviews of individual charts of patients
chosen at random.
payments were modest: $2,672 for individual physicians, $4,270 for the
combined group and $1,648 for the practice level groups. The main
outcomes measured included patients who achieved guideline-recommended
blood pressure thresholds or received an appropriate response to
uncontrolled blood pressure or had been prescribed medications
recommended in national guidelines (Seventh Report of the Joint National
Committee on Prevention, Detection, Evaluation, and Treatment of High
Blood Pressure). Directors of the participating hospital regions
contributed $250,000 for the incentives.
there were changes in the measurements of physician plus health care
team and the practice level groups, none were statistically significant,
which Petersen found surprising.
thought that if you incentivize a whole team of care - physicians,
nurses, clerks, pharmacists - the effect would be powerful. You would
get everyone's incentives on the team aligned and all working better
together," she said.
other side of the coin, some had been concerned that providing
incentives might result in patients being over treated. However, the
study found no difference in low blood pressure (hypotension) between
the incentive groups and the controls.
that it might be possible to simplify the methods of reviewing patient
records using a database. If so, it might be possible to roll out a
similar plan more cheaply and widely, she said.
who took part in this work include: Kate Simpson, Tracy H. Urech, Drs.
Kenneth Pietz, Sylvia J. Hysong and Jochen Profit, all of the Health
Policy, Quality and Informatics Program of the Michael E. DeBakey VA
Medical Center Health Services Research and Development Center of
Excellence and Baylor College of Medicine; Dr. Douglas A. Conrad of the
University of Washington Department of Health Services; and Dr. R. Adams
Dudley of University of California San Francisco.
for this work came from: the Veterans Affairs Health Services Research &
Development (HSR&D) Investigator-Initiated Research (IIR) 04-349; the
National Institutes of Health (NIH) (Grant RO1 HL079173-01); the
American Recovery and Reinvestment Act of 2010 (NHLBI 1R01HL079173-S2),
and the Houston VA HSR&D Center of Excellence (HFP90-020); the American
Heart Association Established Investigator Award (Grant number
0540043N), the Robert Wood Johnson Foundation Generalist Physician
Faculty Scholar (Grant number 045444) all to Petersen as principal
investigator; National Heart, Lung and Blood Institute (NHLBI)
Investigator Research Supplement to Promote Diversity in Health-Related
Research (Grant 1R01HL079173-S1) to Hysong; a VA HSR&D Career
Development Awardee (CDA 07-0181) to Hysong; Eunice Kennedy Shriver
National Institute of Child Health and Human Development (Grant #1 K23
HD056298-01) to Profit; Robert Wood Johnson Foundation Health Care
Financing and Organization Program (Grant number 63214) to Conrad;
Robert Wood Johnson Investigator Awardee in Health Policy to Dudley.
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