Cost of Adherence: Shared Financial Incentives Lead to LDL Cholesterol Reductions

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For patients with cardiovascular disease, the cost of not taking prescribed medications can be worse outcomes, increased hospitalization and even death. Nevertheless, about half of patients who are prescribed statins stop taking them within a year. A study presented at the 2015 American Heart Association conference (JAMA 2015;314(18):1926-1935) found that paying both physicians and patients to work toward adherence resulted in modest improvements in the patients’ LDL cholesterol levels.

Patients and primary care physicians who had shared financial incentives achieved significant reductions in low-density lipoprotein (LDL) cholesterol, according to a cluster randomized trial. However, the initiative to lower LDL cholesterol did not work if patients or physicians could not share the money.

“The superiority of a shared approach makes sense because success at LDL [cholesterol] reduction is likely to be driven by both provision of medication by physicians and patient adherence to that medication,” David A. Asch, MD, of the University of Pennsylvania, and colleagues wrote. “Consistent with this hypothesis, patients in the shared group were more likely to receive medication intensification and to adhere to medication use than patients in other groups.”

The researchers enrolled 1,503 patients with high cardiovascular risk between 2011 and 2014 at the University of Pennsylvania in Philadelphia, Geisinger Clinic in Danville, Pa., and Harvard Vanguard Medical Associates in Boston.

They selected 340 physicians and randomly assigned patients and physicians to one of four groups: a control group in which patients and physicians did not receive any money for meeting LDL cholesterol goals; a group in which the physicians were eligible to receive up to $1,024 per enrolled patient meeting LDL cholesterol goals; a group in which the patients could receive up to $1,024 if they met LDL cholesterol goals; and a group in which patients and physicians shared the $1,024 if they met the LDL cholesterol goals.

The patients received an electronic pill bottle for statins. The bottles did not provide audible or visual reminders, but it did wirelessly transmit a signal to the web platform when opened. The patients had a goal of reducing their LDL cholesterol by at least 10 mg/dL every quarter or achieving or maintaining a LDL cholesterol level less than 100 mg/dL for high-risk participants or 130 mg/dL for medium-risk participants.

If patients met their goal each quarter, they were eligible to receive payment. Physicians received monthly reports on their patients’ LDL cholesterol levels. They also could track their patients’ adherence and progress on a web platform.

All patients received up to $355 for participating in the trial.

After 12 months, patients in the control group had a mean reduction in the LDL cholesterol of 25.1 mg/dL, patients in the patient incentives group had a mean reduction of 25.1 mg/dL, patients in the physician incentives group had a mean reduction of 27.9 mg/dL and patients in the shared physician-patient incentives group had a mean reduction of 33.6 mg/dL.

The patients in the shared physician-patient incentives group were the only ones to have a significant reduction in LDL cholesterol compared with the control group. The shared group also had a significant reduction in LDL cholesterol compared with the patient incentives group and the physician incentives group.

A post hoc analysis found 49 percent of patients in the shared physician-patient incentives group, 40 percent of patients in the physician incentives group, 40 percent of patients in the physician incentives group and 36 percent of patients in the control group had achieved their LDL cholesterol goals at 12 months. The LDL cholesterol values remained stable at 15 months.

Although the shared incentive and patient incentive groups had higher medication adherence rates, the researchers said the rates were low in all groups.

During the 12 months, the incentive payments were a mean $3,246 per enrolled physician in the physician incentives group, $172 per enrolled patient in the patient incentives group and $1,597 per enrolled physician and $118 per enrolled patient in the shared physician-patient incentives group.

“The absence of an effect from physician incentives alone is important,” the researchers wrote. “Physician financial incentives have been deployed for decades to motivate improved processes or outcomes of care, and it seems intuitive and self-evident that paying physicians more for better quality should improve performance. The lack of improvement in LDL [cholesterol] level, despite potential physician incentives of up to $1,024 per patient, offers the first controlled evidence that adding these incentives to a fee-for-service payment model may not improve medication-related intermediate outcomes.”