A recent randomized, controlled trial of the impact of incentive payments based on quality outcomes showed some expected – and unexpected results:
- Individual physician bonuses increased % patients with controlled BP by 8.4%,
- Practice-level bonuses increased % patients with controlled BP by 3.2%
- Combined bonuses increased % patients with controlled BP by 5.5%
This study seems to contradict the hypothesis that team based care improves quality outcomes. The newspaper article below discusses some reasons the team bonuses may have been less effective. I think we can conclude that when physicians stand to gain directly from improved control of chronic disease measures, they will do more to meet those goals.
Petersen, Laura, et al “Effects of individual physician-level and practice level financial incentives on hypertensive care” JAMA 2013;310(10):1042-50. http://jama.jamanetwork.com/article.aspx?articleid=1737042
Houston study finds doctor bonuses produce better care
September 17, 2013
Patients fare better when their doctor receives a bonus for positive results, but they regress after the payment ends, according to a new study of the emerging movement to reward quality rather than quantity.
The study, conducted by Baylor College of Medicine researchers, found significant but not sustained improvement in the blood pressure of patients whose doctor got a modest financial incentive to produce better outcomes. Such incentives are an example of what’s known as “pay for performance,” a key component of health-care reform.
“Pay for performance isn’t a panacea for all that ails health care, but this study shows even modest incentives can be effective in improving care,” said Dr. Laura Petersen, a Baylor professor of medicine and the study’s principal investigator.”It isn’t the only answer, it’s not the sole intervention needed, but this study suggests incentives should be part of the package of reforms that can improve health care.”
Petersen said she was surprised study participants’ blood pressure backslid after the study ended, but didn’t draw the conclusion incentives need to be provided in perpetuity to work. She acknowledged, however, she had expected patients would have developed better habits and sustained improvement.
Also to Petersen’s surprise, the study found that patients did not fare better when the patient’s whole health-care team received incentives.
Petersen said she undertook the research, published in last week’s edition of the Journal of the American Medical Association, because health policy often is adopted because it sounds like a good idea, not because of rigorous scientific evidence in support of it.
Pay-for-performance emerged as one recommended solution to America’s overpriced, under-performing health-care system in the middle half of the previous decade. Health-care economists argued that a system that rewards outcomes would be less wasteful than the current fee-for-service system, whose reimbursement is based on the number of tests ordered or procedures performed.
Petersen, also associate chief of staff for research at Houston’s Michael E. DeBakey Veterans Affairs Medical Center, conducted the study at 12 VA hospital outpatient clinics in five different regions over a 15-month period in 2007 and 2008.
Four groups studied
Eighty-two doctors and 43 support staff members were split into four groups: one in which only the doctor received an incentive; one in which an incentive was split equally among a health-care team; one in which all members of the team received an incentive but the doctor’s was significantly more; and a control group in which there was no incentive.
The study found the incentive to doctors alone resulted in an 8.36 percent increase in patients whose blood pressure was reduced to desired levels or who received appropriate medical intervention when it became clear their high blood pressure couldn’t be lowered sufficiently without drugs. Petersen said the improvement was particularly impressive because blood pressure levels of VA patients nationally already are considered good.
There was not a statistically significant benefit to either of the teams that shared incentives.
The incentives averaged $1,648 when the teams shared equal amounts; $4,270 to the doctors and $1,181 to members of the team in the groups in which the money was unequally allocated; and $2,672 to doctors who alone got the bonus.
Petersen said the disappointing results from the incentivized teams may have been because the VA only made a priority of organizing home-care teams after the study. But Jim Rebitzer, a Boston University professor of management, said it is not uncommon for there to be problems with team incentives.
“The more people in a team, the more the incentive gets diluted, the greater the chances of someone free-riding,” said Rebitzer, who’s written extensively about incentive programs in and out of health care. “It’s not that they can’t work, but as we know from families, groups don’t automatically function at a high level.They take a lot of management.”
Limits to incentives
Rebitzer added that the regressions found after the study ended show the limits of pay-for-performance. He acknowledged that incentives can work well for discrete, specific targets.
He said that would mean spending more time on them and less on something else, something doctors find hard to manage, particularly given the number of conditions that require constant attention for sustained results.
The study was applauded as an important contribution to the field by Rebitzer, Rice University health economist Vivian Ho and Pauline Rosenau, a professor of management, policy and community health at the University of Texas School of Public Health in Houston.
But Rosenau added that “it is sad that health-care providers must be offered a relatively trivial financial incentive to do the job that they should be doing anyway.”
Rosenau added that “pay for performance is here to stay – and patients should know about it. They should ask their doctor if he or she is receiving a bonus and how it might affect their care.”