Despite the well-documented benefits of statins to lower LDL cholesterol (LDL-C) and help reduce cardiovascular-related mortality, research suggests that physicians underprescribe these drugs. Other data indicate that clinicians frequently fail to intensify therapy when appropriate and that patient adherence to these medications is often subpar. The consequences of these actions can be severe among patients with cardiovascular disease, including worse outcomes, higher hospitalization and mortality rates, and increased healthcare costs.
One approach to increase attention to the management of lipids is to tie physician financial incentives to clinical goals, but another strategy may be to offer incentives to patients for reaching their goals. Both of these approaches might be enhanced by applying insights from behavioral economics.
For a study published in JAMA, Kevin G. Volpp, MD, PhD, and colleagues compared the provision of financial incentives for physicians only, for patients only, or for shared incentives for both parties and looked at their effectiveness at reducing LDL-C levels among people with elevated cardiovascular risks. The interventions were tested over 12 months from 2011 to 2014 in three healthcare delivery systems in the northeastern United States.
Doctors in the physician incentive group were eligible to receive up to $1,024 per enrolled patient meeting LDL-C goals. Participants in the patient incentive group were eligible for the same amount, while physicians and patients in the shared incentives group shared these incentives. A control group was also involved in the analysis and received no incentives that were tied to outcomes. That said, all patient participants received up to $355 each for participating in the trial.
"Sharing financial incentives for both patients and physicians was shown to reduced LDL-C levels more than what we saw in the control group and for incentive strategies that involved only physicians or only patients," says Dr. Volpp. Nearly half of patients in the shared patient and physician incentive group achieved their LDL-C goal, compared with rates ranging between 36% and 40% for the other groups.
"The success of the shared approach makes sense because successful LDL-C reduction is likely to be driven by both initiation of therapy and, where appropriate, intensification of therapy by physicians and patient adherence to those medications," adds Dr. Volpp. He notes that the physician-only incentive group had higher rates of intensifying medical therapy and the patient-only group had higher rates of adherence, but only the shared incentive group significantly increased both.
Physician financial incentives like pay-for-performance have been used for decades to motivate improvements in processes of care and to enhance patient outcomes but with limited success, Dr. Volpp he says. The study group notes that while incentives were relatively small, they reflected real-world constraints. They added that increasing the size of a quality incentive per patient may not sufficiently change physician behavior in the context of a fee-for-service payment system that still predominantly rewards physicians for volume throughput.
Asch DA, Troxel AB, Stewart WF, et al. Effect of financial incentives to physicians, patients, or both on lipid levels: a randomized clinical trial. JAMA. 2015;314:1926-1935. Available at: http://jama.jamanetwork.com/article.aspx?articleid=2468891.
Asch DA, Volpp KG. On the way to health. LDI Issue Brief. 2012;17:1-4.
Volpp KG, John LK, Troxel AB, Norton L, Fassbender J, Loewenstein G. Financial incentive-based approaches for weight loss: a randomized trial. JAMA. 2008;300:2631-2637.
Kevin G. Volpp, MD, PhD, has indicated to Physician's Weekly that he is a principal and owner of VAL Health. He also reports having served as a consultant for CVS Caremark and having received grants from CVS Caremark, Hawaii Medical Services Association, Humana, Merck, Weight Watchers, and Discovery (South Africa).