Individual Financial Incentives for VA Providers Result in Better Hypertension Treatment than Audit and Feedback Alone
BACKGROUND:
Evaluations of the effectiveness of pay-for-performance programs have shown contradictory results. This trial tested the effect of financial incentives to individual physicians and practice teams for the delivery of guideline-recommended care for hypertension. Participants included 83 primary care physicians and 42 non-physician personnel (i.e., nurses, pharmacists) who provided care for Veterans with hypertension at one of 12 VA hospital-based primary care clinics. Clinics were randomized to one of four groups: 1) physician-level (individual) incentives, 2) practice-level incentives, 3) physician-level plus practice-level (combined) incentives, and 4) no incentives (control). All received audit and feedback. There were two outcome measures: 1) the number of patients among a random sample who achieved guideline-recommended blood pressure thresholds or received an appropriate response to uncontrolled blood pressure; and 2) the number who were prescribed guideline-recommended medications. Investigators assessed the number who developed hypotension and followed participants for a 12-month "washout period" to determine whether the effect of the intervention was sustained.
FINDINGS:
- VA physicians randomized to the individual incentive group were more likely than controls to improve their treatment of hypertension. The adjusted changes over the study period in Veterans meeting the combined BP/appropriate response measure were 8.8 percentage points for the individual-level, 3.7 for the practice-level, 5.5 for the combined, and 0.47 for the control groups.
- Therefore, a physician in the individual group caring for 1000 patients with hypertension would have about 84 additional patients achieving blood pressure control or appropriate response after 1 year.
- The effect of the incentive was not sustained after the washout period. Although performance did not decline to pre-intervention levels, the decline was significant.
- None of the incentives resulted in increased incidence of hypotension compared with controls.
- While the use of guideline-recommended medications increased significantly over the course of the study in the intervention groups, there was no significant change compared to the control group.
- The mean individual incentive earnings over the study represented approximately 1.6% of a physician's salary, assuming a mean salary of $168,000.
LIMITATIONS:
- The high baseline performance of VA providers, with BP control rates of approximately 75%, may have created a "ceiling effect," whereby performance gains were more difficult to achieve.
AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D (IIR 04-349), and Dr. Hysong was funded by an HSR&D Career Development Award. Drs. Petersen, Hysong, Pietz, Profit, and Woodard and Ms. Urech and Simpson are part of HSR&D's Center of Excellence in Houston, TX.
Petersen LA, Simpson K, Pietz K, Urech TH, Hysong S, Profit J, Conrad D, Dudley RA, and Woodard LD. Effects of Individual Physician-Level and Practice-Level Financial Incentives on Hypertension Care: A Randomized Trial. JAMA September 11, 2013;310(10):1042-50.
