Pay for Performance Boosts HbA1c Testing, but Not Disease Control


A pay-for-performance program designed to improve quality of care for underserved patients succeeded in getting physicians to order more hemoglobin A1c testing in their diabetic patients, as is recommended.

However, improving physicians' compliance with testing recommendations did not in turn improve their patients' control of the disease or affect outcomes, researchers wrote in the Journal of Health Care for the Poor and Underserved.

These findings indicate that earning a bonus for every HbA1c test that is ordered according to guidelines does improve physicians' performance. But patient behavior and other factors are beyond the scope of the physician and contribute heavily to patient outcomes, said Katie Coleman, a research associate at the MacColl Institute for Healthcare Innovation at the Group Health Cooperative, Seattle, and her associates.

“While most pay-for-performance programs have been implemented by managed care companies and other large payers like Medicaid and Medicare, academic medical centers, hospitals, and clinics are starting to look at realigning incentives for their staff physicians as a way to enhance productivity and performance,” the investigators noted.

Yet only a few randomized controlled trials have examined the impact of financial incentives on health outcomes, and none have assessed that impact in medically underserved communities. In addition, the results of these few studies have been mixed, Ms. Coleman and her associates said.

They analyzed data from a large Chicago network of health care organizations to assess how implementing a pay-for-performance program affected outcomes in patients with diabetes. The study involved 1,166 patients treated by 46 primary care physicians.

Almost all of the patients were low-income members of minority groups.

After the physicians were able to earn bonuses for ordering HbA1c tests according to American Diabetes Association recommendations, the proportion of patients who were correctly referred for testing increased from 29% to 46%, a significant improvement.

However, the number of patients with controlled diabetes actually declined slightly during that time, and there was no change in average HbA1c scores after the incentive program was introduced (J. Health Care Poor Underserved 2007;18:966–83).

“Patients spend less than 1% of their time with their doctors, managing their own health care the rest of the time. If you do a purely medical intervention, it really isn't surprising that we don't see major improvements in people's health.

“Pay-for-performance fills in half of the equation. Now we need to find ways to work on the other half—involving patients,” Ms. Coleman said in a statement.

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