The effect that pay-for-performance (P4P) programs have on health outcomes is being questioned by researchers in a new study.

P4P programs provide financial incentives to physicians for the quality of care they provide and patient outcomes. Healthcare information technology is used in these programs to track quality indicators.

[See also: P4P process is all about measuring results.]

A new study published January 26 in the British Medical Journal presents the strongest evidence yet that P4P does not offer any benefit to patients with hypertension, despite the enormous administrative costs required to maintain such a system.

"No matter how we looked at the numbers, the evidence was unmistakable; by no measure did pay-for-performance benefit patients with hypertension," says lead author Brian Serumaga, formerly of Harvard Medical School/Harvard Pilgrim Health Care Institute, but now at University of Nottingham Medical School.

Working closely with researchers at Harvard, Nottingham and the University of Alberta in Canada, Serumaga and his colleagues focused on how P4P might affect outcomes in patients with hypertension, a condition where other interventions such as patient education have shown to be very effective.

The United Kingdom implemented a P4P program called "Quality and Outcomes Framework" in 2004. Analyzing data from the UK's Health Improvement Network, a large database of primary care records from 358 UK general practices, the international research team identified 470,725 patients diagnosed with hypertension between January 2000 and August 2007, spanning four years prior, and three years after, P4P was implemented.

The researchers looked at various measures including blood pressures over time, rates of blood pressure monitoring and hypertension outcomes, as well as illnesses.

Analysis showed that even after allowing for a number of variations, there was no identifiable impact on the cumulative incidence of stroke, heart attacks, renal failure, heart failure or mortality in both patients who had started treatment before 2001 and patients whose treatment had started close to the implementation of P4P.

"Governments and private insurers throughout the world are likely wasting many billions on policies that assume that all you have to do is pay doctors to improve quality of medical care," says senior author Stephen Soumerai, professor in the Department of Population Medicine at Harvard Medical School and Harvard Pilgrim Health Care Institute. "Based on our study of almost 500,000 patients over seven years, that assumption is questionable at best."

[For more information on P4P adoption, see: Progress made on the pay-for-performance front.]

According to Anthony Avery, also of University of Nottingham Medical School, "Doctor performance is based on many factors besides money that were not addressed in this program: patient behavior, continuing MD training, shared responsibility and teamwork with pharmacists, nurses and other health professionals. These are factors that reach far beyond simple monetary incentives."

"Policymakers sometimes legislate large and expensive policies based on their beliefs without the requisite hard evidence," says Soumerai. "Policy makers in the U.S. and in Canada who are attempting to enact such programs need to think hard about other more effective approaches."