Pay-for-performance may benefit doctors who care for very sick

Physicians who treat patients with multiple health problems will fare well under pay-for-performance, which bases physician reimbursement on the quality of care provided, said researchers at Baylor College of Medicine and the Michael E. DeBakey Veterans Affairs Medical Center in Houston in a report in the journal Circulation.

Treatment differences among patients with high blood pressure

When the researchers evaluated the high blood pressure treatment provided to patients who had other serious health conditions, they found that such patients were more likely to receive high quality care than patients who had no co-existing health problems.

"Pay-for-performance raises a lot of fears and assumptions that the reimbursement will not be fair toward doctors who care for the sickest patients," said Dr Laura A. Petersen, the study’s lead author and director of the Houston VA Health Services Research and Development Center of Excellence and an associate professor of medicine at BCM. "What we found was that doctors do a good job of taking care of a lot of complex conditions, even better than they think they do."

Petersen, who is also chief of Health Services Research at BCM, said the result surprised her.

Doctors respond well to more complex medical situations

"When a patient comes in with many problems, there is often less time to address any single one," she said. She and her colleagues found, however, that physicians appear to identify the problems that present the most risk and deal with them effectively.

"This is good news and should be reassuring to doctors and health policy makers," she said.

About the study

The research team chose to study high blood pressure because it is a common, symptomless problem that can have serious consequences, affecting the heart, brain and kidneys.

In their study, the researchers identified 141,609 patients with high blood pressure in a VA database. Of these 22,595 had no other serious health conditions; 70,098 had conditions that could be related to the high blood pressure (concordant), 12,283 other health conditions not related to high blood pressure (discordant) and 36,633 had both.

Blood pressure was controlled for 12,956 (57.3 percent) of patients with no other health conditions, 45,334 (64.7 percent) of those with concordant or related health conditions and 7,742 (63 percent) of those with other conditions not related to blood pressure. Of those with both concordant and discordant condition, 25,339 or 69.2 percent had blood pressure controlled.

Sicker patients get better care

The researchers noted that quality of care increased with the number of other conditions the patient had. In other words, the sicker the patient, the better the care, even after statistically controlling for the numbers of visits with a doctor.

"Our results should be reassuring for policy-makers who have faced crticism that performance measures, public reporting, and pay-for-performance initiatives may penalise health care providers of patients with multiple co-existing chronic conditions," they wrote.

Others who took part in this research include Drs LeChauncy D. Woodard, Louise M. Henderson and Kenneth Pietz and Tracy H. Urech, all at the Houston Center for Quality of Care and Utilization Studies, a Health Services Research and Development Center of Excellence at the Michael E. DeBakey Veterans Affairs Medical Center and the Section for Health Services Research at BCM.

Funding for this work came from US Department of Veterans Affairs, the National Institutes of Health, the Robert Wood Johnson Foundation and the American Heart Association.

(Source: Baylor College of Medicine: Circulation: June 2009)