Pay-for-performance programs (a form of value-based care) are supposed to improve patient care, but a new JAMA study suggests that one hypertension control incentive might be making the numbers look better while actually increasing hospitalizations.
- Financial incentives tied to blood pressure control targets (below 140/90 mmHg) are already widely used across U.S. health systems.
- However, the issue with any threshold-based quality metric is whether it changes care or simply changes documentation.
In an effort to evaluate pay-for-performance, researchers compared outcomes across 334k patients at 103 primary care practices before and after a hypertension control incentive was added to physician contracts at 63 of those practices.
- The incentive first led to a modest increase in blood pressure remeasurement across the full hypertensive population (+1.9 percentage point).
- Researchers didn’t find a statistically significant change in actual hypertension control, medication outcomes, or cardiovascular hospitalizations.
On the surface, that’s a neutral result, but trouble emerged for patients with marginally elevated BP (initial systolic reading of 140 to 145 mmHg).
- Remeasurement probability increased by 5.6 percentage points.
- Meanwhile, documented hypertension control improved by 4.1 percentage points.
- But, the probability of an existing antihypertensive being uptitrated dropped by 1.1 percentage points.
- Then the three-month hospitalization risk for stroke or ACS rose by 0.25 percentage points, growing to 0.52 in one year.
As it turns out, the incentive created a remeasurement loop, not a treatment loop, with physicians retaking blood pressure until a reading falls below the threshold, then moving on without adjusting medications.
The broader implication is a design problem, not a physician problem, and it led to some passionate commentary on X from physicians across specialties.
- One physician breaking down the study reminded us that previous P4P studies labeled incentive design as the problem, not the concept of pay-for-performance.
- Another commenting physician lamented that such incentives drive subpar care as part of the “quality” game.
The Takeaway
Pay-for-performance will likely remain a widely deployed tool in the race for healthcare quality improvement and this study doesn’t argue for abandoning it. What it does point to is the danger of using transient metrics to define success and financial incentives in medicine.
