Financial incentives on hypertension care shows increased blood pressure control

In an examination of the effect of financial incentives on hypertension care at 12 outpatient clinics, physician-level (individual) financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure, according to a study in the September 11 issue of JAMA. None of the incentives resulted in greater use of guideline-recommended medications compared with controls.

"As part of the Affordable Care Act, the U.S. government has introduced pay for performance to all hospitals paid by Medicare nationwide. The New York City Health and Hospitals Corporation recently announced a performance pay plan for physicians. These and other value-based purchasing systems are intended to align incentives to promote high-quality health care. Evaluations of the effectiveness of pay-for-performance programs directed at hospitals have shown contradictory results," according to background information in the article.

Laura A. Petersen, M.D., M.P.H., of the Veterans Affairs Medical Center and Baylor College of Medicine, Houston, and colleagues conducted a randomized controlled trial to test the effect of explicit financial incentives to individual physicians and practice teams for the delivery of guideline-recommended care for hypertension in the primary care setting. The trial at 12 Veterans Affairs outpatient clinics with 5 performance periods enrolled 83 primary care physicians and 42 nonphysician personnel (e.g., nurses, pharmacists). The interventions were physician-level (individual) incentives, practice-level incentives, both, or none. Intervention participants received up to 5 payments every 4 months; all participants could access feedback reports. The primary measured outcomes were the number of patients (among a random sample) achieving guideline-recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure, the number of patients prescribed guideline-recommended medications, and the number who developed hypotension (abnormally low blood pressure).

Among physicians who participated in all 5 performance periods, the average total payment for physicians over the course of the study was $4,270 in the combined physician and practice-level group, $2,672 in the individual physician-level group, and $1,648 in the practice-level group. Change in blood pressure control or appropriate response to uncontrolled blood pressure compared with the control group was greater only in the individual incentives group. The difference in change in proportion of patients achieving blood pressure control or receiving an appropriate response between the individual incentive and no incentive group was 8.36 percent.

Although the use of guideline-recommended medication increased over the course of the study in the intervention groups, there was no change compared with controls.

The researchers did find that far more intervention than control group participants viewed their feedback reports on the website (67 percent vs. 25 percent), suggesting that participants were aware of the relationship between performance and rewards.

"Although concerns about overtreatment have been cited in criticisms of pay-for-performance programs, we did not find a higher incidence of hypotension in the panels of physicians randomized to the incentive groups," they write.

Even small reductions in blood pressure translate into significant reductions in morbidity and mortality, and in system-wide costs, the authors write. "This trial addresses the needs of policy makers and payers for information about a clinically relevant payment intervention in routine practice. Payment-system interventions are attractive because of their potential scale and reach. However, payment-system interventions are only one piece of the solution to improve management of chronic diseases such as hypertension. More resource-intensive, tailored, patient-level self-management strategies may be needed to truly affect patient outcomes."