Hypertension: does “pay-for-performance” deliver quality care?

Nowadays, health care practitioners are reimbursed on a “pay-for-performance” basis also called P4P which rewards physicians financially for achieving targets and treatment goals. The financial rewards can vary from increase in percentage of reimbursements, bonuses, and grants. Even though the P4P program aims to promote better health care delivery, it can backfire when doctors may avoid patients with complex disorders (and therefore more difficult goals to achieve) and opt more for patients with simple, straightforward ailments (e.g. easy targets). As an example, patients with diabetes are also likely to present with concomitant illnesses such as high blood pressure, heart disease, and other cardiovascular disorders.

Researchers looked followed up 141,609 patients with high blood pressure from at eight Veterans Affairs (VA) hospitals in three states. They compared quality of care and patient satisfaction between patients with simple hypertension and those who are “sicker” hypertensive patients, e.g. with other co-existing conditions, from diabetes to chronic lung diseases.

According to lead author Dr. Laura A. Petersen of the VA Health Services Research and Development Center of Excellence and affiliated with the Baylor College of Medicine, in Houston, Texas

“Many clinicians are concerned that when they care for patients with multiple medical conditions, their performance on measures of health care quality is going to suffer due to that complexity. The concern is that the time spent treating other unrelated conditions would take away time from treating high blood pressure, causing performance on measures of quality to suffer.”

The results of the study show that:

• “Sicker patients” are more likely to receive high quality health care.
• Patients with multiple diseases have to take many types of medications but expressed an overall high satisfaction with the medical care they receive.
• Patient satisfaction is generally positive regardless whether patients are treated for high blood pressure only or for other conditions as well.

“Overall good quality care” was defined as:

• When doctors managed to keep blood pressure under 140/90 millimeters of mercury (mm Hg) at first visit and within the six-month follow-up period.
• When doctors are actively trying to control blood pressure (even if the patient fell short of the treatment goal) as shown by intensified follow-up care that would include change in medication, nutrition and lifestyle change counselling, etc.

The study results indicate that P4P measures do not necessarily “penalize physicians who treat patients with more complicated medical conditions”, at least in the case of hypertensive patients.

One weak point of the study is the fact that it looked only at patients under the VA system which essentially differs in a lot of ways from the civilian health care system.

However, the results of the study should be a reassurance to both health care practitioners and patients alike that indeed the P4P program seems to be also achieving its goal – quality health care.