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Paying doctors for better care improves quality: studies

By Andrew M. Seaman

NEW YORK (Reuters Health) - Paying doctors in small practices bonuses for the quality of care they provide leads to a modest increase in the number of patients who get the recommended treatment for their conditions, according to a new study.

Researchers found that doctors who received bonuses had more patients receiving recommended medications, having their blood pressure under control and being given tools to help them stop smoking, compared to doctors not receiving bonuses.

"Payment structures can help people focus on preventive care elements in a setting where patients are sick and there are a lot things going on," Dr. Naomi Bardach, the study's lead author from University of California, San Francisco, told Reuters Health.

The hope would be that focusing on preventive measures, such as blood pressure and cholesterol, would lead to better health for patients and ultimately save money over several years.

Most studies looking at doctor bonuses were conducted in large healthcare systems, but most Americans get their care from offices run by only a handful of doctors, write Bardach and her colleagues in The Journal of the American Medical Association.

For the new study, they randomized 84 small, New York City medical practices that were using electronic medical records to one of two groups, which were followed between April 2009 and March 2010.

One group of 42 practices received bonuses for each patient who was appropriately prescribed aspirin, prescribed a smoking cessation treatment and had their blood pressure and cholesterol under control.

The bonuses did not exceed $200 per patient.

The other 42 practices didn't receive bonuses, but did get quarterly performance reports - as did the practices that received bonuses.

The average characteristics of each practice - such as patients' ages, sex and insurance - were not different between the two groups.

At the end of the study, all practices in the study increased the percentage of patients who met the guidelines, but those people seeing doctors who received bonuses were more likely to be getting guideline-based care than those in the practices without bonuses.

For example, between 53 and 54 percent of patients in all practices were receiving appropriate aspirin therapy at the beginning of the study. That increased to 61 percent in the practices not receiving incentives and about 65 percent in practices that got bonuses.

The proportion of patients with controlled blood pressure increased to about 62 percent in practices receiving bonuses from about 52 percent at the start. That compared to about a 4 percentage point increase in the comparison group.

Practices that received bonuses also did slightly better at ordering smoking cessation treatment for their patients, compared to practices in the other group.

There was no difference between groups for cholesterol control, but Bardach says that may be partially explained by most patients having safe cholesterol levels at the study's start.

Overall, $692,000 in bonuses was paid to the practices. The money could be reinvested into the practices or go home with the doctors.

"I don't think our findings say having a financial incentive cures everything, but it can help people pay attention to things that are easy to miss when there are other things going on in a clinic visit," Bardach said.

While Bardach's study found improvements with incentives over one year, another study published in the same journal had mixed results.

Dr. Laura Petersen and colleagues from the Michael E. DeBakey Veterans Affairs Medical Center and the Baylor College of Medicine in Houston found that doctors improved along guidelines measuring how many of their patients got their blood pressure under control and how well doctors responded to uncontrolled pressure.

But those improvements were only found when doctors personally received the bonuses - not when the bonus went to the practice or was split between the doctor and practice.

"I thought if you'd get people's motivations all lined up that they'd work together well… It just didn't happen," Petersen said.

She added, however, that the two studies' findings are in line with each other, because Bardach's study included very small doctors' offices and "the practices are so small that they're like individual incentives."

"These two studies show that, when well-designed, modest incentives can be effective at improving performance," she said.

Her team found, however, that removing the bonuses led to the measures returning to what they were at the study's start.

In an editorial accompanying the new studies, Drs. Rowena Dolor and Kevin Shulman from the Duke University School of Medicine in Durham, North Carolina, wrote that more studies are needed to test whether bonus and incentive programs like these are sustainable over several years.

Dolor also told Reuters Health that allowing doctors to earn bonuses is only part of the solution to the healthcare system's woes.

"The answer is more complex than just studying one (method). There is more coordination needed and the incentives need to be across different levels," she said, adding that incentives could also apply to people other than doctors, such as nurses, health coaches and possibly patients.

SOURCE: http://bit.ly/JOTmp1 The Journal of the American Medical Association, online September 10, 2013.

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