Two studies in the Sept. 11 issue of the Journal of the American Medical Association looked at the effect that providing pay-for-performance incentives had on cardiovascular care and blood pressure.
Both studies saw improvements in care when doctors received incentives, but those improvements were modest.
"I think the reason the incentives didn't have as much of an impact is that there are so many pieces to the health care puzzle, and the clinician is just one. There's also a patient piece, and a health care system piece, and a technology piece when you're trying to meet population health goals," said Dr. Rowena Dolor, co-author of an accompanying journal editorial.
"Maybe if we can align all those pieces so that they come together, we could make larger improvements in health care," added Dolor, who is an associate professor of internal medicine at Duke University in Durham, N.C.
The first study included small primary practice groups in New York City who had a high percentage of Medicaid patients. To be included, the practice had to have fewer than 10 doctors. There were 42 practices in the incentive group and another 42 in the comparison ("control") group that did not use incentives.
A city program provided the doctors with electronic health records software and assistance for using it. Incentives provided to the doctors varied, based on the patient. A doctor would be given an extra $40 for a patient with a chronic illness. If someone had a chronic illness and no insurance, the incentive jumped to $80, said Dr. Naomi Bardach, lead study author and an assistant professor of pediatrics at the University of California, San Francisco. The maximum incentive per patient was $200.
Blood pressure control was achieved in nearly 10 percent of patients without diabetes or a heart condition called ischemic vascular disease in the incentivized practices, but in just over 4 percent of the control group.
Aspirin or other blood thinners were appropriately prescribed for 12 percent of patients with diabetes or ischemic vascular disease in the incentivized practices, but only for about 6 percent of patients in control group practices. Smoking cessation treatment was offered to more than 12 percent of smokers in the practices receiving incentives, compared with about 8 percent in the group without incentives.
Bardach noted that while there's still a long way to go to get to 100 percent, there was a more than 50 percent increase in the number of patients with blood pressure control, and nearly a 50 percent increase in the number of patients receiving appropriate blood-thinning medications.
"We paid doctors more for doing what is harder to do. If a patient was sicker or likely to have more trouble managing the system, we paid more for achieving the same outcome," said Bardach, who added that there were no performance penalties, only incentives.
The second study was conducted at 12 Veterans Affairs outpatient clinics, and included 83 primary care physicians and 42 non-physician personnel, such as nurses and pharmacists. The study groups were individual physicians receiving an incentive, incentives to a practice, incentives to both a physician and a practice, or no incentive to either the physician or the practice. An individual physician could earn nearly $3,000 for meeting certain outcomes.
The study looked at whether patients achieved blood pressure levels according to guidelines, if providers responded appropriately to patients' uncontrolled blood pressure, the number of patients prescribed guideline-recommended blood pressure medications, and the number of patients who developed low blood pressure.
The difference between patients meeting their blood pressure goals or an appropriate response to uncontrolled blood pressure was 8.36 percent between the group receiving incentives and the group not given an incentive.
In the editorial, Dolor suggests using technology to get patients more involved. For example, they could have access to care portals on the computer. Both patients and providers could receive electronic reminders for follow-up appointments, prescriptions and more. Health management teams in clinical practices could track patients who are struggling with their health goals and focus more attention on them and their needs, Dolor and her co-author suggested.
Incentives in such a system would be targeted at the leadership, she wrote, so that they would be held accountable for the performance of the health management teams.
Technology such as Dolor proposed is already available in some practices. Electronic health records are making their way into most primary care practices, largely due to government incentives to implement this technology. Among other capabilities, electronic health records provide automatic reminders for lab work, prescriptions and follow-up appointments.
A third study in the same issue of the journal found that the use of electronic health records in people with diabetes decreased the number of emergency department visits and hospitalizations significantly. However, there was no reduction in the number of office visits.
Read more about electronic health records at HealthIT.gov.