Does pay for performance encourage doctors to follow medical guidelines, as has been suggested by healthcare pundits? 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, wonders if pay for performance would help solve healthcare issues — particularly as they relate to blood pressure guidelines.
Petersen questioned whether pay for performance would solve certain health care issues or simply create new ones. She also wondered, how does one structure payments for a pay-forperformance model? As Dr. Petersen is a recognized expert in healthcare services and quality of care, she set up a multi-year study that took in 83 doctors and 42 other health care individuals from 12 different Veterans Affairs hospital-based outpatient clinics.
Petersen and collaborators discovered that moderate increases in monetary incentives to doctors demonstrated a significant increase (8.36 percent) in the number of patients who were able to lower their blood pressure to desired levels. This also followed suit with individuals whose blood pressure was uncontrolled, who received an appropriate medical response to their condition. The researchers also found that monetary incentives to a whole healthcare team or healthcare team and doctor did not have a significant effect. Petersen and colleagues also report that there was no change in the control group that received no incentives.
Petersen points out, the findings certainly will not solve all health care issues, but has an effect in improving care. She believes that pay for performance is alluring, as it can be a system-wide plan that could be managed on a wide scale. She went on further to say, “We were able to demonstrate that this type of program can be carried out at 12 different sites at one time. We were able to demonstrate a significant effect in the VA health care system where high blood pressure (hypertension) is already controlled overall. Previous studies have reported that baseline blood pressure control rates in the VA system are currently at 75 percent.”
According to the current study, a primary care doctor who has 1,000 patients would have 84 additional patients who would meet high blood pressure goals after one year. Petersen believes this is a significant effect. Petersen notes that, according to the current study, during the year the incentive program ended, the effects began to decrease. She believed that the initial trend would continue, however, it didn’t. She thought, after a long intervention, doctor’s practices would change over time. Nevertheless, the current study indicates that incentives are working. In fact, if their performance didn’t drop, then one might question whether the incentives brought about the change to begin with.
The way the experiment was designed was to have clinics assigned to one of four incentive groups. This involved doctor-level incentives only, practice-level incentives, combined physician and practice incentives and a non-incentive control group. The incentive groups were paid every four months for five periods. Groups received feedback on their performance on their ability to control blood pressure. Recommended medications remained constant throughout the testing period. Blood pressure changes that occurred were documented in reviews of individual charts of patients who were chosen at random.
The researchers report that total payments to individual physicians was moderate, at $2,672 and $4,270 for the combined group and $1,648 for practice level groups. The results included patients who made recommended blood pressure thresholds or received an appropriate response to uncontrolled blood pressure or those who had been prescribed medications that were recommended in national guidelines according to the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. Incentive monies came from the directors of the participating hospital regions to the tune of $250,000.
Although changes in the measurements of health care team plus physician groups and the practice level groups occurred, they were not statistically significant. Peterson apparently found this surprising, She felt that if you provide incentives to a whole care team, the effects would be strong simply because everyone would be working as a team.
Petersen notes that, on the other hand, some health care providers were concerned that providing incentives might end up having patients over treated generating low blood pressure. However, the study found no difference in hypotension (low blood pressure) between the incentive groups and controls.
At this point, Petersen would like to simplify reviewing patients records by using a database. Then, it might be possible to design a plan that would be inexpensive to run and could be widely used to collect more information on the validity of incentive programs.