Financial Incentives and Lipid Levels

For some time payers have used financial incentives to change care delivery and hopefully improve quality, partly by encouraging public reporting on measures and partly by rewarding actual performance on those measures.  While usually directed to providers, some of the incentives may be given to patients.  Research in the Journal of the American Medical Association explores whether financial incentives available to providers, patients or both can aid in lowering lipid levels.   (JAMA Article)  In this study, primary care physicians, and the patients the physician was responsible for, either had no incentives, a physician only incentive, a patient only incentive or a shared incentive.  The main outcome over the length of the 12 month study was a change in LDL-C level.  The patients were on a lipid-lowering medication and their adherence was tracked and the physicians and patients had access to regular reports on the patients’ progress toward their objective.   The physicians in the intervention group could get $256 quarterly payments for each patient who met goal.  Patients could win up to $100 a day by matching random digits but only if they had taken their medication.  The odds were they would win $1022 per year if they took their drugs.  In the shared group physicians could get half the incentive available to doctors in the physician only group and patients also were only eligible for half the incentive.

Patients in the control group, where neither doctors nor patients had incentives, had a mean reduction in LDL-C level of 25 mg/dL.  Patients in the shared incentives group had an average decrease of 33.6 mg/dL.  Patients in the physician only incentive group saw an average 28 mg/dL decline, while those in the patient only group had a 25.1 mg/dL decrease. Only the reduction in the shared incentives group reached statistical significance.  49% of patients in the shared incentive group reached their goal, compared to 40% in each of the physician only and patient only groups and 36% in the control group.  Adherence to drug regimens declined in all groups but was highest among the shared incentive patients.  Incentive payouts were significant.  It is notable that only those patients and physicians with shared incentives showed a significant reduction, although even that was relatively modest.  The lack of results from physician only incentives is particularly disappointing.  The patient incentive did improve medication adherence, which is beneficial, but it remained relatively low overall.  And the cost was relatively high; it is unclear whether there would be enough cost savings to cover the expense of the incentives.  As has other research, this study suggests that financial incentives are not necessarily a guarantee of better quality.