Increasing physicians’ bonus sizes was linked to significantly improved quality of care for their patients, according to a study from a single health system published Feb. 8 in JAMA Network Open. However, adding the behavioral economic principles of social pressure and loss aversion failed to further improve providers’ effectiveness.
“P4P (pay-for-performance) has not produced consistently positive results,” lead author Amol S. Navathe, MD, PhD, with the University of Pennsylvania, and colleagues wrote. “Several explanations have been proposed, including that incentive sizes are too small and baseline performance on quality metrics is too high, reflecting little opportunity to improve; extrinsic incentives may crowd out intrinsic motivation; and the design of programs (eg, high-performance targets) only incentivizes physicians with performance near the thresholds.”
Despite the mixed results of pay-for-performance programs, health insurers and healthcare systems have increasingly employed them in an effort to incentivize clinicians to provide higher-value care.
To test the effectiveness of multiple strategies, Navathe et al. randomized physicians 1:1:1 within Advocate Physician Partners—an integrated physician network based in Downers Grove, Illinois—to receive larger bonuses alone, receive those bonuses with a loss aversion incentive or receive larger bonuses with increased social pressure applied. All of the physicians in those intervention groups were compared to propensity-matched physicians within Advocate who weren’t receiving a larger bonus.
Overall, the authors found an increase in maximum bonus size in 2016 of 32 percent per physician—equaling approximately $3,355, or $16 per patient—was linked to small but statistically significant gains in quality of care. Each provider was assessed on a weighted percentage of 20 evidence-based quality measures they achieved for their patients, and those with larger bonuses averaged 3.2 percent higher on the composite score than those without bonus increases, after adjustment for patient and physician characteristics.
In unadjusted analyses, patients receiving care from physicians in the larger bonus size (LBS) group scored 89.2 percent on a composite score for evidenced-based care in 2016, up from 85 percent in 2015 before the bonuses went into effect. Patients in the non-LBS group had an increase of 2 percentage points from 2015 to 2016 (86.2 percent to 88.2 percent).
“Our results suggest that in a general primary care physician program with substantial bonus sizes and a large budget, further increases in bonuses were associated with gains in quality,” the researchers wrote. “However, they should also be interpreted with caution given a unique, single-institution setting in which the group exposed to LBS was lower performing and may have had a greater opportunity to improve.”
A total of 33 physicians treating 3,747 patients were randomized to the LBS interventions and included in the final analysis. Fourteen of the doctors were family medicine practitioners, while 13 specialized in internal medicine, four in pediatrics and two in other specialties. They were all treating patients with at least one of five chronic conditions: asthma, chronic obstructive pulmonary disease, type 2 diabetes, congestive heart failure and coronary artery disease or ischemic vascular disease.
Despite the observed impact of larger bonuses on patient care, Navathe et al. found adding loss aversion (LA) or increased social pressure (ISP) to the equation didn’t further improve quality. LA was modeled by putting 50 percent of physicians’ expected incentives based on their prior year’s performance into a virtual account. Physicians were able to access this money through an email request but were required to pay back funds if they earned fewer pay-for-performance dollars than they extracted.
The ISP intervention increased the proportion of a physician’s composite quality score associated with group performance from 30 percent to 50 percent, and also identified physicians with scores below the performance threshold.
“Adding LA and ISP did not lead to further quality improvements, although attrition and a small sample size limited statistical power,” Navathe et al. wrote. “Further refinement of applications of behavioral economic principles in P4P design should be tested with larger sample sizes.”
When analyzing individual quality measures, the authors found only three were significantly increased in LBS physicians versus the comparison group: blood pressure control (1.6 percent increase versus 4.3 percent decrease), receiving a foot examination with a diabetes diagnosis (7.5 percent increase versus 0.4 percent increase) and tobacco cessation (6.5 percent increase versus 1.1 percent decrease).