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The risk that diabetic patients would be hospitalized was 25% lower (incidence rate ratio 0.75, 95% CI 0.61 to 0.93) among those seen for three consecutive years by physicians who received extra pay for meeting quality-of-care targets, compared with the risk for patients whose physicians did not receive such incentives.
High-quality care — defined as receiving at least two tests for glycated hemoglobin (HbA1c) and one for LDL cholesterol during a given year — was delivered 16% more often by physicians in the pay-for-performance system.
“This study showed a robust, consistent, significant, and positive association between increased receipt of appropriate laboratory monitoring of A1c and LDL cholesterol levels and decreased hospitalization rates,” Judy Y. Chen, MD, MSHS, of IMS Health in Woodland Hills, CA, and colleagues declared. On the other hand, the researchers also found that quality of care diminished when patients saw multiple primary care physicians during a given year.
“This finding supports the hypothesis that patients have better outcomes when they have a medical home.”
The researchers examined records of diabetic patients enrolled with Hawaii Medical Services Association, a large preferred provider organization, from 1999 to 2006. The plan had about 19,600 such patients in 1999 and 32,365 in 2006.
The plan offered physicians in the network the opportunity to earn bonuses of 1.5% to 7.5% of their base fees for meeting care-quality targets including HbA1c and LDL cholesterol testing of diabetic patients. Bonuses ranged from $10,000 to $16,000 annually. Starting in 2001, physicians could earn an extra $6,000 if their adherence to care-quality processes improved over the previous year. Bonuses were paid each year on the basis of administrative records for the previous year.
The proportion of diabetic patients seen by physicians in the pay-for-performance plan increased from 78.7% in 1999 to 94.6% in 2006. As a result of the bonus structure, improvements in care quality lagged implementation of these incentives by a year or two.
The most substantial improvements in quality of care and patient outcomes were seen among patients seen continuously by a physician participating in the pay-for-performance system from 2004 to 2006.
Compared with patients seen by physicians who chose not to participate in the system, those whose treatment was subject to the incentives were seen by primary care physicians and endocrinologists far more often:
- Six to 10 outpatient visits in a year: odds ratio 2.16 (95% CI 2.00 to 2.33)
- Eleven or more outpatient visits in a year: OR 2.35 (95% CI 2.14 to 2.57)
- Visit to an endocrinologist: OR 1.56 (95% CI 1.38 to 1.75)
Among patients receiving quality care continuously from 2004 to 2006, the chance of being hospitalized in 2006 was reduced by 33% compared with patients whose care failed to meet the quality target at some point. But patients who saw more than two different primary care physicians in 2006 had a dramatically increased rate of hospitalizations.
The study also included only one clinical outcome; effects on others such as hypoglycemic episodes, cardiovascular events, and meeting HbA1c targets were not measured and might have been different.
The researchers also acknowledged that the claims data underlying the study might not have been totally accurate, and they noted that it did not include other factors known to affect hospitalizations such as cardiovascular risk factors.
Chen J, et al “The effect of a PPO pay-for-performance program on patients with diabetes” Am J Manag Care 2010; 16: e11-e19. |