Pay-for-Performance Intervention Improves Blood Pressure Control among Black Veterans with Hypertension without Unintended Consequences

BACKGROUND:
Hypertension is more prevalent, more severe, and more resistant to treatment in blacks than in whites, and the mortality rate from hypertension is higher in blacks than whites. Several observational studies have found that performance incentives, such as those in pay-for-performance programs, have the potential to improve, worsen, or maintain the quality of healthcare for minorities. This study sought to evaluate the effect of a pay-for-performance intervention on the quality of hypertension care provided to black Veterans. Investigators randomized 12 VAMC primary care clinics to one of four groups: 1) physician-level (individual) incentives, 2) practice-level incentives, 3) physician- and practice-level (combined) incentives, and 4) no incentives (control). All physicians at a particular hospital were assigned to the same group (50 to incentive groups and 17 to control groups). For this study, patients were classified as "black" only if their race was "black or African American" and their ethnicity was "not Hispanic, Spanish, or Latino." Primary data were collected between 2007 and 2009. Primary measures included the proportion of black Veterans with hypertension who received guideline-recommended antihypertensive medications, proportion of patients with controlled blood pressure (BP), and the proportion with uncontrolled BP who received an appropriate clinical response to an uncontrolled BP (e.g., lifestyle recommendation for stage 1 hypertension or medication adjustment). Risk selection also was measured: risk selection is a phenomenon whereby condition severity and complexity influence providers to select patients out of a primary care panel to improve the overall measured performance of the panel. Among physicians who participated in each of the five 4-month performance periods, the average total payment was $2,744.

FINDINGS:

• VA physicians who received performance incentives for meeting guideline-recommended hypertension quality measures demonstrated better performance than control group physicians on a combined measure of BP control or appropriate clinical response to uncontrolled BP in black Veterans. The proportion of black patients who achieved BP control or received appropriate response to uncontrolled BP was 6% greater for physicians who received an incentive.
• There was no evidence found for risk selection, i.e., there was no difference between intervention and control groups in the proportion of Veterans who switched providers, and there were no differences in visit frequency or panel turnover, creating reassurance that the incentives did not have negative unintended effects on the care of black patients.

LIMITATIONS:

• Investigators were unable to assess the effects of various incentive types – or test a varying amount of incentives, or responses to larger incentives.
• Data used for this study are from 2007-2009.
• It is unclear whether the difference between the incentive and usual care groups (6%) in BP control or appropriate response translates into long-term clinical benefits for patients.

AUTHOR/FUNDING INFORMATION:
This study was partly funded by HSR&D (IIR 04-349). All authors are part of HSR&D's Center for Innovations in Quality, Effectiveness and Safety (IQuESt) in Houston, TX.

Petersen LA, Ramos K, Pietz K, Woodard L. Impact of a Pay-for-Performance Program on Care for Black Patients with Hypertension: Important Answers in the Era of the Affordable Care Act. Health Services Research. June 22, 2016; Epub ahead of print.