Shared Cash Incentives Help Patients, Providers Meet Goals

Susan London

November 18, 2015

Use of financial incentives to reduce low-density lipoprotein cholesterol (LDL-C) levels in primary care is effective only when patients and physicians share those incentives, suggests a cluster randomized trial published in the November 10 issue of JAMA.

The researchers conducted the 12-month trial in three US healthcare systems using a fee-for-service model. The researchers randomly assigned patients and physicians to the shared incentive group, the patient-only incentive group, the physician-only incentive group, or the control group, in which no incentives were given. Results showed that a strategy of shared incentives, whereby the patient and physician split about $1000 if they achieved an LDL-C goal, significantly reduced levels, with a difference of 8.5 mg/dL when compared with the control group. In contrast, there was no significant relative reduction when the incentives were given to either party alone, or to the control group.

"The superiority of a shared approach makes sense because success at LDL-C reduction is likely to be driven by both provision of medication by physicians and patient adherence to that medication," the authors write.

"This reduction was modest, however, and further information is needed to understand whether this approach represents good value," they conclude.

The findings are really not unexpected, according to first author David A. Asch, MD, director of the Center for Health Care Innovation at the University of Pennsylvania, professor at the Perelman School of Medicine and the Wharton School, and a physician at the Philadelphia Veterans Affairs Medical Center in Philadelphia, Pennsylvania.

"Doctors and patients need to work together toward important clinical goals, so we shouldn't be too surprised that the combination, the sharing of incentives, is what's required to get people to the finish line," he commented in a prepared audio statement. "I think this study demonstrates that shared incentives can work in achieving important patient goals."

The type of payment model a system uses may influence the effectiveness of various incentive strategies, noted senior author Kevin G. Volpp, MD, PhD, director of the Center for Health Incentives and Behavioral Economics, a professor at the School of Medicine and the Wharton School of the University of Pennsylvania, and a staff physician at the Philadelphia Veterans Affairs Medical Center.

"What we find in this study is that layering provider incentives to improve quality on top of fee-for-service reimbursement does not work very well. This may seem counterintuitive, but it really reflects the fact that the predominant incentive that doctors in these systems faced was still related to providing fee for service and really focusing on the volume of services they provided," he commented in the audio statement. "In these types of settings, where patient engagement is critically important to improving health metrics, it seems important to think about shared incentive programs that really bring both providers and patients into the mix together."

"This is the first study to have ever examined the question of shared incentives for providers and patients, and it provides proof of concept that these types of shared incentive programs might be an important way for us collectively to improve the health of populations going forward," he further noted. "But it's going to be really important to think about and to test ways to improve on this program and really design increasingly more effective, more cost-effective shared incentive programs."

Participants in the study were 340 primary care physicians and 1503 adult patients who had a 10-year Framingham Risk Score of 20% or greater, had coronary artery disease equivalents with LDL-C levels of 120 mg/dL or greater, or had a Framingham Risk Score of 10% to 20% with LDL-C levels of 140 mg/dL or greater.

After 12 months, patients in the shared incentives group had achieved an average 33.6 mg/dL (95% confidence interval [CI], 30.1-37.1) reduction in LDL-C levels, which was significantly greater than the 25.1 mg/dL (95% CI, 21.6-28.5) reduction in the control group. In contrast, reductions in the physician incentives group (27.9 mg/dL; 95% CI, 24.9-31.0) and in the patient incentives group (25.1 mg/dL; (95% CI, 21.6-28.5) did not differ significantly from those seen in the control group.

Overall, 49% of the patients in the shared incentives group achieved their LDL-C goal compared with 36% in the control group and 40% each in the patient incentives and the physician incentives groups (P = .03 for comparison of all four groups).

Additional findings further indicated that both physician and patient behaviors played a role when the incentives were shared. The proportion of patients whose medication was intensified (meaning they were started on a statin or, if already receiving a statin, had an increase in dose or drug potency) was 38% with shared incentives compared with 27% with control. And patient adherence to medication was 39% with shared incentives compared with 27% with control (P < .001).

The study was interesting and well designed, and brings new information to the field, said Donald D. Hensrud, MD, MPH, an associate professor of preventive medicine and nutrition at the Mayo Clinic, Rochester, Minnesota, in an interview with Medscape Medical News. "The results kind of speak for themselves, and they intuitively make sense. If you have a shared relationship between a physician and a patient, there is more strength in that than if either the physician or the patient is receiving motivation from financial incentives," he commented.

Dr Hensrud agreed that the relative 8.5 mg/dL reduction in LDL-C levels with the shared approach was modest, although he thought the control group fared quite well. "You could add Zetia [Merck & Co, Inc] (ezetimibe) to a statin and obtain a little bit better result than that," he noted.

A critical question, especially in light of the modest gain, is who is going to pay for the incentives, according to Dr Hensrud. Given the number of patients and the amount of the incentives in the trial, "[t]hat's not an inexpensive incentive to give people," he elaborated.

Dr Asch and Dr Volpp reported being principals and owners of VAL Health. One coauthor reported serving on the scientific advisory board of VAL Health. Another coauthor reported having received grants from Geisinger Health System, Merck, AstraZeneca, Genentech, and the National Association of Chain Drug Stores, as well as other support from the Academy of Managed Care Pharmacy. Dr Volpp also reported having served as a consultant for CVS Caremark and having received grants from CVS Caremark, Humana, Merck, Weight Watchers, and Discovery (South Africa). The other authors and Dr Hensrud have disclosed no relevant financial relationships.

JAMA. 2015;314:1926-1935. Full text

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