' News of the Day #444 - Bonus pay has scant effect on treatment, outcomes

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Bonus pay has scant effect on treatment, outcomes

A central premise of Medicare planners in recent years has been the idea that medical practice will be improved by “pay for performance.” But a just-completed pilot project has shown that financial incentives did not significantly improve compliance with guidelines. (Thomas M. Burton and Theo Francis, Wall St J 6/6/07).

There was also no significant difference in the odds of in-hospital mortality in patients with non–ST-segment elevation acute myocardial infarction at pay-for-performance sites.

The 54 hospitals participating in the CMS project received financial bonuses, while the 446 “control” hospitals did not. The performance measures included use of aspirin, ACE inhibitors or angiotensin receptor blockers, beta blockers, and advice to quit smoking. Over 3 years, compliance rose from 88% to 94.2% at the P4P hospitals, and from 88% to 93.6% at the others, P = .16.

Authors of the study concluded: “The results of the study raise concerns about what magnitude of effect pay-for-performance programs should have to justify the administrative burden and potential unintended consequences of financial incentives” (Glickman SW, et al. JAMA 2007;297:2373-2380).

The study did not turn up evidence of deterioration in quality measures not subject to incentives, including use of glycoprotein II/IIIa inhibitor, clopidogrel at discharge, heparin use, or lipid-lowering medication; dietary counseling; prompt EKG and cardiac catheterization; and referral for cardiac rehabilitation.

A prominent cardiologist not associated with the study, Steven E. Nissen, chairman of cardiovascular medicine at the Cleveland Clinic, told the Wall Street Journal that the results “suggest we ought to slow down a minute before going into pay-for-performance.”

Duke cardiologist Eric D. Peterson, a coauthor of the JAMA article, said “one read on this is that the carrots have to be bigger.”

Funding sources included Bristol-Myers Squibb/Sanofi Pharmaceuticals and the Schering-Plough Corporation.

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