How Effective is Pay-for-Performance In Improving VA Healthcare Outcomes?

by U.S. Medicine

November 6, 2013

By Brenda L. Mooney

Laura Petersen, MD, MPH

HOUSTON — Should pay-for-performance be more widely used to incentivize VA clinicans to improve healthcare quality?

That was the question raised by a new study finding that modest financial incentives paid to individual VA physicians resulted in a more than 8% improvement in either bringing patients’ blood pressure under control or providing an appropriate response to uncontrolled blood pressure.

The study, led by researchers from the Michael E. DeBakey VAMC in Houston, sought to determine the effectiveness of pay-for-performance inducements in healthcare. The results were published recently in the Journal of the American Medical Association (JAMA).

“We showed that individual incentives were effective when directed at physician providers in the primary care setting,” said lead author Laura Petersen, MD, MPH, director of the Houston VA Health Services Research and Development Center of Excellence and professor of medicine at Baylor College of Medicine, also in Houston.

Research failed to show, however, that incentives to a whole healthcare team or to the physician and healthcare team together had a significant effect in improving care.


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Ivan Monserrate, MD, takes veteran Thomas Brock’s blood pressure at the Washington, DC, VAMC. A new study sought to determine if pay-for-performance could improve hypertension care at the VA.

“In this study, we were interested looking to see whether there is evidence that pay for performance is effective in healthcare,” Petersen explained in a video interview provided by JAMA. “Often when we are trying to decide whether to implement a new screening approach or new therapeutic approach, we look and see what the evidence is. But in payment system interventions, the evidence and evidence base is surprisingly thin.”

The VA was chosen for the research because of the single payment approach of salaried medical staff, she said, adding, “There are no other insurance plans and ways of reimbursing providers and performance targets that could contaminate the intervention, so it was an ideal setting.”Participants included 83 physicians and 42 other healthcare personnel in12 VAMCs throughout five regions.

Prior to the intervention, baseline blood pressure control rates in the VA system were already at 75%, according to study background.

For the study, clinicians 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. With incentives paid every four months for five periods, feedback reports detailing performance in controlling their patients’ blood pressure also were provided to those who took part.

Interestingly, incentive payments — contributed by directors of the participating hospital regions who came up with a total of $250,000 for the project — were fairly modest at $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 (i.e., the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure).

While the combined physician-healthcare teams and the practice level groups showed some improved, none proved statistically significant.Petersen said that, in two arms of the study, practice teams were included “because we were interested in patient-centered medical home and new models of accountable care and whether incentives directed to the practice team would also be effective.”

As it turned out, only incentives targeted at individual physicians reached statistical significance in improving guideline-recommended care of hypertension.

“This would translate into, for a physician primary care panel that included a 1,000 patients with hypertension, to about 85 additional patients after a year of exposure to the intervention having the combined outcome of achieving blood pressure control or having an appropriate response to an uncontrolled blood pressure,” she noted.

“I really 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,” Petersen added in a Baylor College press release.

Researchers determined that the unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75% to 84% and 8.84% (95% CI, 4.20% to 11.80%) for the individual group, 80% to 85% and 3.70% (95% CI, 0.24% to 7.68%) for the practice-level group, 79% to 88% and 5.54% (95% CI, 1.92% to 9.52%) for the combined group, and 86% to 86% and 0.47% (95% CI, -3.12% to 4.04%) for the control group.

“These changes in the use of guideline-recommended medications were not significant in any of the incentive groups compared with controls, nor was the incidence of hypotension,” the authors write. “The effect of the incentive was not sustained after a washout.

On the positive side, the study uncovered no unintended consequences to using the incentives, Petersen said, explaining, “We looked to see whether patients of providers who received the interventions were more likely to suffer from hypotension, or low blood pressure, as a result of treatment. Unintended consequences have been a significant concern for healthcare providers, and we feel our findings are reassuring regarding this potential unintended consequences.”

She said she was disappointed that the positive effects diminished in the year after the incentive program ended.

“I thought the change would continue,” Petersen 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.”

Noting that “individual financial incentives, but not practice-level or combined incentives, resulted in greater blood pressure control or appropriate response to uncontrolled blood pressure; none of the incentives resulted in greater use of guideline-recommended medications or increased incidence of hypotension compared with controls,” the authors called for further research on factors contributing to the findings.

  1. Petersen LA, Simpson K, Pietz K, Urech TH, et. al. Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial. JAMA. 2013 Sep 11;310(10):1042-50. doi: 10.1001/jama.2013.276303. PubMed PMID: 24026599.


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