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Performance-related financial incentives not associated with improved outcomes
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 pay-for-performance
CHICAGO—A pay-for-performance program at hospitals was not associated with significant improvement in processes of care or outcomes for heart attack patients, according to a study in the June 6 issue of JAMA.

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“The concept of providing financial incentives to health care givers to improve quality of care, known as pay for performance, has received national attention as a potential means of narrowing well-documented gaps between health care guidelines and clinical practice,” the authors write. In 2003, the Centers for Medicare & Medicaid Services (CMS) launched the largest pay-for-performance pilot project to date in the United States, including indicators for acute myocardial infarction (heart attack). Participating hospitals with the highest performance measures would receive a reimbursement bonus, while those with the poorest performance risked future financial penalty.

Seth W. Glickman, M.D., M.B.A., of Duke University Medical Center, Durham, N.C., and colleagues examined whether hospitals participating in the pay-for-performance program showed improvement in certain process measures and outcomes for treatment of heart attack beyond that in hospitals not participating in the quality-improvement program. The study included an analysis of data for 105,383 patients with acute non–ST-segment elevation myocardial infarction (a certain pattern on an electrocardiogram following a heart attack). Patients were treated between July 2003 and June 2006 at 54 hospitals in the CMS program and 446 control hospitals.

The researchers found that composite measure scores for CMS processes showed significant improvement at both pay-for-performance and control hospitals. There was no significant difference in the rate of improvement in the composite score between the two hospital groups. Two of the six CMS measures, aspirin prescription at discharge and smoking cessation counseling, had slightly higher rates of improvement at pay-for-performance hospitals than control hospitals. For composite measures of heart attack treatments not subject to incentives, rates of improvement were not significantly different. There was a slight reduction in the rate of deaths over time at both pay-for-performance and control hospitals, although the difference in the rate of the reductions between the groups was not statistically significant.

“In conclusion, this study is one of the first to evaluate the CMS pay-for-performance pilot project. Among hospitals participating in a voluntary quality-improvement registry, pay-for-performance had limited incremental impact on processes of care and outcomes for acute myocardial infarction. Conversely, we did not find evidence that pay-for-performance had an adverse impact on improvement in processes of care that were not subject to financial incentives. Additional studies of pay-for-performance are needed to determine its optimal role in quality-improvement initiatives,” the researchers write.
(JAMA. 2007;297:2373-2380.

Editor's Note: Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

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