Giving hospitals bonuses for good performance — a favored idea in federal health policy — results in only modest improvements in the quality of care, according to a new study.
The study, released online Friday by the New England Journal of Medicine, comes amid a push by the federal government to make more quality-of-care data public and link reimbursement to them.
On Friday, the federal Centers for Medicare and Medicaid Services announced that it will award $8.7 million in incentive payments to top-performing hospitals taking part in a large pay-for-performance project managed by Premier Inc., a consortium of nonprofit health systems.
The New England Journal study compared results over a two-year period from 207 hospitals taking part in the Premier study with those from 406 other hospitals that aren't offered such reimbursement bonuses.
Both groups of hospitals are part of an initiative to make their quality-of-care data public.
The study looked at how often the hospitals provided certain treatments, such as giving antibiotics to pneumonia patients within four hours of arrival or immediately giving aspirin to heart-attack patients.
The pay-for-performance hospitals performed better on all the quality measures but the differences were small after adjusting for certain variables, such as hospital size and patient volume.
Pay-for-performance hospitals provided the measured treatments 2.6% more often for heart attack patients, for instance, and 3.4% more often for pneumonia patients.
The effect of performance bonuses was "very modest," said Peter Lindenauer, a professor of medicine at Tufts University School of Medicine and the study's lead author.
He also noted that the study didn't attempt to assess patient outcomes or the cost of administering such programs.
In an accompanying editorial in the New England Journal, Arnold Epstein, a professor of health policy and management at the Harvard School of Public Health, said the findings "still leave us with many uncertainties" about how to best use such reimbursement strategies to improve patient care.
Peter K. Lindenauer, M.D., M.Sc., Denise Remus, Ph.D., R.N., Sheila Roman, M.D., M.P.H., Michael B. Rothberg, M.D., M.P.H., Evan M. Benjamin, M.D., Allen Ma, Ph.D., and Dale W. Bratzler, D.O., M.P.H.
Background Public reporting and pay for performance are intended to accelerate improvements in hospital care, yet little is known about the benefits of these methods of providing incentives for improving care.
Methods We measured changes in adherence to 10 individual and 4 composite measures of quality over a period of 2 years at 613 hospitals that voluntarily reported information about the quality of care through a national public-reporting initiative, including 207 facilities that simultaneously participated in a pay-for-performance demonstration project funded by the Centers for Medicare and Medicaid Services; we then compared the pay-for-performance hospitals with the 406 hospitals with public reporting only (control hospitals). We used multivariable modeling to estimate the improvement attributable to financial incentives after adjusting for baseline performance and other hospital characteristics.
Results As compared with the control group, pay-for-performance hospitals showed greater improvement in all composite measures of quality, including measures of care for heart failure, acute myocardial infarction, and pneumonia and a composite of 10 measures. Baseline performance was inversely associated with improvement; in pay-for-performance hospitals, the improvement in the composite of all 10 measures was 16.1% for hospitals in the lowest quintile of baseline performance and 1.9% for those in the highest quintile (P<0.001). After adjustments were made for differences in baseline performance and other hospital characteristics, pay for performance was associated with improvements ranging from 2.6 to 4.1% over the 2-year period.
Conclusions Hospitals engaged in both public reporting and pay for performance achieved modestly greater improvements in quality than did hospitals engaged only in public reporting. Additional research is required to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs.
Notice: This article was published at www.nejm.org on January 26, 2007. It will appear in the February 1 issue of the Journal.
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source: http://content.nejm.org/cgi/content/short/NEJMsa064964v1 29nov2007