Is it more effective to financially incentivize only the doctor, only the patient, or both doctor and patient to achieve a higher quality health care treatment outcomes? 

That’s the question asked by a new University of Pennsylvania study that comparatively analyzed the potential of these three different pay-for-performance (P4P) strategies in a three-year project involving clinicians and patients at Penn Medicine, the Geisinger Clinic and Harvard Vanguard Medical Associates. 

“This was an extremely complex study involving more than 1,500 patients and 340 physicians in three different health systems,” said Andrea Troxel, Senior Statistician in the research project that split doctors and patients into four groups: control, physician incentives, patient incentives, and physician-patient shared incentives.

The study was published this week in the Journal of the American Medical Association (JAMA).  In an unusual move, JAMA published a separate article lauding the  statistical methods used by the Penn research team in this very complicated project.

Best results: pay both
The bottom-line finding: paying financial incentives to both the doctor and the patient achieved the best results.

The Penn study was focused on a single physician-patient treatment issue: the use of statins to reduce LDL-C cholesterol levels in patients at high risk for coronary artery disease. But its results appear to provide new insights into the current government-funded programs of clinician-centric P4P incentive policies and practices. 

The study group in which only the doctors were paid incentives achieved results that were not significantly different from the control group in which no one was paid.

Statistically significant reduction
Patients in the control group achieved a mean reduction in LDL-C levels of 25.1 mg/dL over 12 months. Patients in the doctor-and-patient incentivized group achieved 33.6 mg/dL reduction.

“We probably shouldn’t be surprised by these results,” said  Troxel, a Professor and Associate Director of Biostatistics at Penn’s Perelman School of Medicine. “After all, achieving reduction in LDL cholesterol requires first that physicians prescribe appropriate medications, such as statins, to patients, and second that patients take these medications regularly. Patients and physicians are most effective at achieving health goals when they work as a team. The shared incentives are an effective way of reinforcing and rewarding that teamwork.”

The 16-member Penn research team was headed by David Asch, Kevin Volpp and Troxel. Asch, MD, MBA, is Executive Director of the Penn Medicine Center for Innovation and a Professor of both Medicine and Medical Ethics at Penn’s Perelman School of Medicine and Health Care Management at the Wharton School, and an LDI Senior Fellow. Volpp, MD, PhD, is the Director of LDI’s Center for Health Incentives and Behavioral Economics (CHIBE), a Professor of both Medicine and  Health Care Management and an LDI Senior Fellow. Troxel, ScD, is also CHIBE’s Director of Biostatistics and an LDI Senior Fellow.

‘First controlled evidence’
“The absence of an effect from physician incentives alone is important,” Troxel and her colleagues wrote in their JAMA article. “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-C level, despite 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.”

Various pay-for-performance strategies have been built into health care reimbursement systems over the years but the concept was greatly expanded in the wake of the Affordable Care Act. It’s estimated that there are currently over 100 P4P health care-related programs being operated and assessed in various ways across the country but this study, according to Troxel, is unique.

Innovative in three ways
“This study is innovative in at least three ways,” she explained.  “First, we used modern concepts of behavioral economic theory to design the interventions for both patients and physicians.  Second, we leveraged modern technology both to implement the interventions and to streamline the data collection.  Third, we applied state-of-the-art research methods to randomly assign physicians and their patients to the intervention groups and to evaluate their clinical responses.”

“As a result,” Troxel continued,  “the study provides the first thorough exploration of the relative value of incentives to patients, incentives to physicians, or incentives shared between patients and physicians. Those shared incentives are significantly more effective than the others, and this reinforces our understanding of the value of teamwork between patients and their doctors when it comes to achieving their health goals.”