Provider incentives don’t lead to overtreatment

Despite widespread implementation of pay for performance (P4P), there has been little data-other than opinions-to guide policymakers about the size of incentives that are needed for an effect, according to a study published in the Journal of the American Medical Association.

Laura A. Petersen, MD, MPH, associate chief of staff, research director, VA’s Health Services Research and Development Service in Houston, and colleagues studied 12 Veterans Affairs outpatient clinics, each of which were assigned to one of three different P4P groups rewarding hypertension-management metrics or a control.

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. 

Dr. Petersen and colleagues found that VA physicians randomly assigned to the individual modest-incentive group were more likely than the control group providers to improve their treatment of hypertension. 

 “Although concerns about overtreatment have been cited in criticisms of pay-for-performance programs, we did not find a higher incidence of hypotension-indicating overtreatment-in the panels of physicians randomized to any of the incentive groups,” Dr. Petersen says.

The mean individual incentive earnings over the study represented approximately 1.6% of a physician’s salary, assuming a mean salary of $168,000, “proving that modest incentives can be effective,” she says.

Few studies in the past have assessed whether P4P gains are sustained.

“We showed that performance declined significantly, although did not decline to baseline levels,” she said. “We speculate that this is because the incentive did not result in any system-level improvements that might have sustained the effects. The effect we found was significant, but the high baseline performance of VA providers with blood pressure control rates of approximately 75% may have created a ‘ceiling effect,’ whereby gains in performance were more difficult to achieve than they might be in a non-VA healthcare setting. Therefore, the improvements might have been greater in a system where baseline performance was lower.”

She says as similar types of P4P initiatives are instituted by the Patient Protection and Affordable Care Act, more research into the way providers and patients respond to incentives will be important to guide healthcare policy.

“Pay for performance is becoming increasingly common,” says Dr. Petersen. “The VA has had a physician performance pay plan in place for several years.  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 healthcare.”

Despite widespread implementation, evaluations of the effectiveness of P4P programs have shown contradictory results, according to Dr. Petersen. 

This article originally appeared in Formulary.