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SPH team conducts checkup on proposed national health-care reform

By Tim Stoddard

	Gary Young, an SPH associate professor of health services, is studying the effectiveness of Rewarding Results, a national program to improve health care by providing financial incentives to physicians and hospitals. Photo by Kalman Zabarsky

It's a clinical trial of sorts, an experimental therapy for the nation's health-care system. Starting in January, seven physicians groups and hospitals around the country will pay cash bonuses to doctors who provide high-quality care to their patients. Supported by the Robert Wood Johnson Foundation and the California Health Care Foundation, the $8.8 million Rewarding Results program is designed to help employers, health plans, and state Medicaid agencies encourage physicians to deliver better and safer care. It sounds like a good idea, but a team of SPH researchers wants to find out if it will actually work.

Led by Gary Young, an SPH associate professor of health services, the team has spent the past year helping the seven demonstration sites -- the HMOs and employers participating in Rewarding Results -- develop incentives for guiding physician behavior. With a $1.5 million grant from the federal Agency for Healthcare Research and Quality, a branch of the Department of Health and Human Services, Young and his colleagues will evaluate how these rewards affect health outcomes and patient satisfaction, and then make recommendations on how to improve the incentives and encourage other health-care providers to follow suit.

“Our role is to promote the scientific integrity of this experiment,” Young says, “and to determine what far-reaching lessons can be learned and replicated in the future.”

Rewarding Results follows upon a series of scathing critiques of the American health-care system. In 1999 the Institute of Medicine, the branch of the National Academy of Sciences that advises Congress on health policy, reported that as many as 98,000 Americans die each year in hospitals from preventable medical errors. Then in 2001 the institute released a second report, entitled “Crossing the Quality Chasm,” which asserts that the nation's health-care system “harms too frequently and routinely fails to deliver its potential benefits.” The report called for Medicare, Medicaid, and other government programs to reward high-quality health care with higher fees or bonuses to the best doctors, hospitals, and HMOs.

But how to measure high-quality care? In Rewarding Results, it's not so much good bedside manner as access to basic tests and services that can prevent major illnesses or nip them in the bud. “A lot of the quality goals that we're looking at focus on the delivery of preventive measures,” Young says, “which have a tremendous potential for improving quality of care so that patients don't need hospitalization and more complex procedures to begin with.”

For instance, most of the seven demonstration sites will track how doctors care for diabetic patients. Every year, tens of thousands of Americans develop diabetes-related complications -- limb amputations, blindness, kidney failure, and premature death -- that could be avoided by monitoring blood sugar levels. In Rewarding Results, physicians who provide simple blood sugar level tests, say every six months, are rewarded with a modest cash bonus.

The quality measures also focus on other chronic diseases, such as asthma and heart disease. For over a decade, doctors have known that patients who take inexpensive drugs called beta-blockers immediately following a heart attack have a dramatically lower chance of a second heart attack. But according to the Institute of Medicine, inadequate care of heart attack victims (including failure to prescribe beta-blockers) results in 18,000 deaths a year. In Rewarding Results, a hospital that gives beta-blockers and aspirin to all heart attack patients will qualify for higher reimbursement. Similarly, physicians who provide routine mammograms to women over age 50, or who provide colorectal cancer screening tests to a certain percentage of patients over age 50, will also receive bonuses.

For physicians meeting these criteria, the sum of the bonuses might range from $5,000 to $10,000, says Dan Berlowitz, a MED associate professor of medicine and one of the core faculty on the team. “This variation creates a natural experiment, because there will be differences in the amount of incentives received, and we'll see whether small ones have as much of an effect as large ones.”

The health insurers will also experiment with nonfinancial incentives, such as report cards that rate physician performance. These reports will be circulated among physicians, and in some cases to the general public. “None of the sites will make public individual physician performance,” Young says, “but some will publicize the performance of physician group practices.”

“Most of the measures that we're looking at are fairly well established,” Berlowitz says. “There's only one group that is trying to do something cutting-edge in terms of quality measurement, and they are trying to come up with a way to measure how well clinicians are diagnosing and treating obesity in children.” With childhood obesity already at epidemic proportions in America, Berlowitz says, there's a pressing need for better care for the disease. “But it's such a difficult problem to approach that I'm not sure physicians can really do much better,” he says.

Careful what you wish for
As Young and his colleagues evaluate Rewarding Results, they'll be looking for unintended consequences of the program's carrot-on-a-stick approach. By encouraging doctors to focus on cancer screening and diabetes checkups, Young says, the program may drop the ball in other areas. “Several physicians have expressed concern that if you give them several goals to focus on, then sure, that's where they'll put their time and energy if you pay them enough,” he says. “But then what about the other things that they should be doing?”

Young compares this scenario to the consequences of schools' using standardized tests. Opponents of such tests claim that schools have become so focused on improving student performance on the tests that teachers are teaching to the tests and excluding other important material. “By seeking to channel the students' thoughts and attention and energy in a particular direction,” Young says, “you may be very much encouraging them to ignore other things that they normally wouldn't.”

7 November 2003
Boston University
Office of University Relations