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Quality Incentives Found Effective for Health Care Outcomes

Naomi Bardach

Naomi Bardach (University of California at San Francisco)

A test of financial incentives for delivering high quality health care shows patients of medical providers receiving those pay-for-performance incentives have better outcomes for a number of common conditions than patients receiving care through the traditional fee-for-service model. The research team from University of California in San Francisco and New York City Department of Health and Mental Hygiene published its findings today in the Journal of the American Medical Association (paid subscription required).

The study, designed as a randomized clinical trial, tested the effects of offering financial incentives to medical providers for improving the overall health of their patients, compared to conventional methods of charging for individual services, known as the fee-for-service model. The Affordable Care Act expands pay-for-performance in Medicare and encourages experimentation to find effective pay-for-performance designs and programs.

The researchers tested the two financial models among small primary care practices — those with a clinical staff of 10 or less — in New York City participating in the eHearts program of the city’s Department of Health and Mental Hygiene. All 84 practices in the study served high proportions of Medicaid patients, had common electronic health record systems, and were randomly assigned to receive either pay-for-performance incentives or the usual fees for services. The team collected data on health outcomes from April 2009 through March 2010 for 7,634 patients, 4,592 in pay-for-performance clinics and 3,042 in fee-for-service practices.

“Pay-for-performance’ programs,” says UCSF pediatrics professor and the paper’s first author Naomi Bardach, “shift the focus from basic care delivery to high quality care delivery.” Clinics in the pay-for-performance group received rewards for each patient that met objectives for preventing heart disease and stroke, such as controlling hypertension, reduced smoking, cholesterol control, and aspirin regimens. Higher payments were also made for patients suffering from multiple conditions, such as diabetes and heart conditions, as well as those on Medicaid or without insurance.

The results showed the pay-for-performance clinics had higher rates of aspirin prescriptions for stroke prevention, blood pressure control, and smoking cessation. The differences were modest in some cases, but as Bardach explains, among this population many patients were starting off at high risk of heart attack and stroke. “The numbers are meaningful,” says Bardach, “because the rates of blood pressure control were so low to begin with, for instance, only 10 to 16 percent of patients with diabetes had normal blood pressure control, so an improvement of even 5 percent of patients is relatively quite large.”

The authors note that the study measured outcomes for less than a year, and long-term results of the pay-for-performance model still need to be assessed.

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