Pay-for-Performance, EHRs and Small Practices

Research looking at the effects of pay-for-performance initiatives often look at large physician practices.  A study in the Journal of the American Medical Association instead focuses on small physician practices to determine how quality does or does not improve under pay-for-performance.  These small practices are where a majority of Americans still receive care and historically have had worse quality performance.    (JAMA Article)   The study was conducted among 1-10 physician practices in New York City, largely in poorer neighborhoods, and with offices that implemented EHRs.  Some of these small practices received an incentive and some didn’t, on a random assignment basis.  The incentive was paid on each patient for whom quality measures improved and was higher for patients whose care likely would be more intensive.  The total possible incentive was about 5% of salary.  The measures were primarily related to cardiovascular risk–lowering blood pressure and cholesterol, taking daily aspirin and stopping smoking.  A total of 84 clinics participated in the study and they had low to moderate performance on the quality measures at baseline, with the exception of lipid levels, which were well controlled.  Both the study and control group showed improvement in quality measures during the research period, but the intervention group showed a greater increase in performance on most measures, including use of aspirin and blood pressure control.  The authors conclude that the incentive did lead to faster improvement and also attribute it to having an EHR which provided clinical decision support and prompting.  Since all groups had the EHR, however, it is not clear that this on its own was a factor.  And another shortcoming here is any showing of improvement in end health or economic outcomes.