In the health system improvement world, paying hospitals and other providers more to improve medical care (Pay For Performance or P4P) has been hailed as a slam dunk, no-brainer to bolster quality and lower costs. In this week’s Journal of the American Medical Association (click here), the promising idea slams into reality. P4P was the only concrete cost-control initiative included in the MA health reform law. Here are excerpts from today’s Kaiser Health Policy Report:
Hospitals participating in a Medicare pay-for-performance pilot program were not significantly more likely than non-participating hospitals to provide better treatment, according to a three-year study published in the Journal of the American Medical Association. … researchers at Duke University compared the treatments and outcomes for five conditions at 54 hospitals participating in a Medicare pay-for-performance pilot program with treatments and outcomes at 446 hospitals not participating in the program.
The researchers studied information on 105,383 patients treated at the hospitals over three years beginning in 2003, examining factors such as whether heart attack patients were prescribed aspirin, beta-blockers and ACE inhibitors. The researchers also tracked whether patients were advised to quit smoking. Hospitals participating in the pay-for-performance program received bonuses if they reached the two highest performance levels for a given condition. Bonuses totaling $17.6 million were awarded to 123 hospitals during the first year of the study and 115 hospitals in the second year. The lowest-performing hospitals faced potential financial penalty, but no penalties were imposed, the researchers said.
According to the study, the “pay-for-performance program was not associated with a significant incremental improvement in quality of care or outcomes” for heart attacks. Compliance with recommendations for heart attack treatment increased to 94.2% from 87% at hospitals participating in the program, compared with an increase to 93.6% from 88% at hospitals that were not in the program. The researchers said they found a “slightly higher rate of improvement for two of six targeted therapies” but concluded that “overall, there was no evidence that improvements in in-hospital mortality were incrementally greater at pay-for-performance sites.”
Study author Eric Peterson said, “One read on this is that the carrots have to be bigger.” The Journal notes that participating hospitals this winter said the bonuses paid were small in proportion to their total budgets. Peterson added that all 500 of the hospitals in the study had volunteered for an initiative to improve adherence to the heart attack treatment guidelines of the American College of Cardiology and the American Heart Association. That participation also might have improved overall performance, Peterson said. Steven Nissen, chair of cardiovascular medicine at the Cleveland Clinic, said that the study’s results “suggest we ought to slow down a minute before going into pay for performance.” The Journal reports that the study’s findings “raise the question of what [CMS] will do next.”
This study helps further understand what might work and might not in changing clinical practice patterns and behaviors. However, since this looked at hospital care for only one diagnosis (acute MI), conclusions from this study shouldn’t be applied too broadly. While it may be (as the editorial states) that the “carrot” needs to be larger, it is also possible that how the program was presented to clinicians or how the incentives were allocated to individual clinicians was not adequate to significantly change behaviors, i.e. were the programs goals clearly presented as improving patient care or just a “research project, and were the financial incentives “awarded” to small enough groups of clinicians so that they could feel that their individual actions would actually be rewarded? There are certainly other factors that can lead to the success or failure of any incentives program – whether it uses a carrot or a stick – but this one study shouldn’t be seen as a stake in the heart of P4P, despite what some proponents of national, government-run healthcare might say.