Fiscal incentives may flop if docs perceive roadblocks

Does it pay to use financial incentives to try to improve the quality of care in hospitals? Possibly not, if physicians perceive factors such as patient nonadherence as being beyond their control, according to one study in the October issue of the American Journal of Managed Care.

Pay-for-performance programs can be designed to reward physicians for following evidence-based, patient-management guidelines such as the Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 7). These programs may provide a variety of financial incentives for individuals or teams who meet performance measures based on guidelines.

But the success of the incentive initiatives may hinge on how committed physicians are to meeting goals, observed Sylvia J. Hysong, PhD, of the Michael E. DeBakey Veterans Affairs Medical Center in Houston, and colleagues. They wanted to study the relationship between financial incentives and goal commitment using a clinic-level randomized trial that compared four scenarios: no financial incentives (a control group); physician-level incentives; group-level incentives; and physician/group combination-level incentives.

Hysong and colleagues enrolled 83 full-time primary care physicians at 12 Veterans Affairs medical centers who completed a presentation on JNC 7 guidelines for treating patients with hypertension and a questionnaire to evaluate their knowledge and attitudes. Physicians completed online surveys every four months as well as phone interviews at eight and 16 months to measure their goal commitment. Those in incentive groups received performance-based financial rewards every four months for five consecutive periods.

Each group undertook audits and received feedback reports that showed the percentage of patients meeting measures, the amount earned if they were in an incentive group, and performance goals for the next period. The researchers tracked participant visits to the feedback reports.

They determined that of the physicians who received a feedback report, a mean 42.45 percent viewed the report. Using quantitative and qualitative analyses, they found that goal commitment remained the same over time and did not differ by incentive group. In the interviews, physicians identified patient nonadherence as the main barrier and consistent patient follow-up as the main facilitator to improving hypertension management.

“[P]hysicians might believe the outcome of hypertension care is mostly a patient responsibility, and thus perceive that they have little control over outcomes,” Hysong and colleagues wrote. “Therefore, they would see no benefit in committing to a goal that they perceive as unachievable.”

Financial incentives may not provide a sufficiently strong intervention to overcome the influence of external forces on physicians’ commitment to meeting performance goals, they observed. “More research is needed to better understand the behavioral levers triggered by financial incentives in the clinician population, so as to better target both pay-for-performance and other quality improvement initiatives,” they wrote.

The authors noted that their study sample was small but wrote that their findings may inform efforts to improve the quality of care in hospitals.