Extra Pay Does Not Improve Hospital Performance
DURHAM, N.C. – Paying hospitals extra money does not appear
to significantly improve the way they treat heart attack
patients or how well those patients do. But giving hospitals
the information that they need to improve heart attack care
A team of researchers led by the Duke Clinical Research
Institute looked at whether financial incentives to
hospitals for adhering to specific treatment guidelines would
improve patient outcomes. They found no evidence that financial
incentives were associated with improved outcomes, nor that
hospitals had shifted their focus from other areas in order to
concentrate on the areas being evaluated for possible increased
These findings will add to the national debate over the use
of "pay for performance" as a strategy for encouraging
hospitals to use drugs and therapies that have been proven to
save lives in large-scale clinical trials, the researchers
said. The theory is that the possibility of receiving higher
reimbursements will motivate hospitals to improve the quality
of their care.
A study recently conducted by Premier, Inc., a group that
represents hospitals participating in a large Center for
Medicare & Medicaid Services (CMS) pilot project of pay for
performance, found that paying hospitals extra money for
following specific guidelines led to better patient care and
outcomes. However, that study did not include a group of
hospitals not receiving incentives as a comparison. So the Duke
team compared the CMS data with that of a registry of 105,383
patients treated for a heart attack at 500 hospitals involved
in a national quality improvement effort.
"This is one of the first analyses of the impact of a pay
for performance initiative on heart attack care," said Seth
Glickman, M.D., M.B.A., first author of a paper appearing June
6, 2007, in the Journal of the American Medical Association.
"We found that the pay-for-performance program was not
associated with a significant incremental improvement in the
quality of care or outcomes for patients with heart attacks
beyond that seen with voluntary quality improvements."
"There are three important messages from this study," said
cardiologist Eric Peterson, M.D., senior member of the research
team. "On one hand, the data showed that care is improving
overall in the United States, which is obviously good. However,
we did not find that pay for performance alone will be the sole
means of improving care. In fact, it all comes down to hard
work by individual caregivers and institutions.
"Here, it appears that a voluntary effort to 'do good and
improve care' was equally as powerful as the incentive for
additional payment," Peterson said. "Finally, heart attack
mortality declined significantly over time in
pay-for-performance and non-pay-for-performance hospitals over
time with better care processes. The bottom line is that
patients win when health care providers are committed to
improvement, no matter what the incentive is."
The researchers looked at how all hospitals performed in six
measurements of quality: the use of aspirin and beta blockers
both at arrival to the hospital and at discharge, smoking
cessation counseling, and the use of angiotensin-converting
enzyme (ACE) inhibitors or angiotensin receptor blockers for
weakened left pumping chambers. These measures were selected
because clinical trials have proven that their use improves the
outcomes for heart attack patients.
The monetary incentive for the CMS study was relatively
small. Over a two-year period, a total of $17.55 million was
paid to 123 hospitals the first year and to 115 hospitals the
"Medicare's strategy of trying to use the payment system to
improve performance of hospitals is certainly laudable," said
Kevin Schulman, M.D., professor of medicine and business
administration at Duke and study co-author. "However, we really
need a robust research base to inform the design of the program
and clearly we need to continuously monitor performance to
ensure that we are achieving our clinical goals through these
Glickman noted that "additional studies are underway to
identify hospital policies and organizational characteristics
that are associated with a higher standard of care in order to
develop more effective incentive based strategies."
The team plans to organize a larger effort involving the
major cardiology associations.
"We've partnered with the cardiovascular professional
societies to have an ongoing national heart attack quality
improvement initiative known as ACTION," Peterson said. "No
matter what incentive will ultimately be the driving force,
ACTION will give hospitals and health care providers the tools
and data they need to improve."