Effect of Physician, Patient Financial Incentives on Lipid Levels
What is the relative impact of physician financial incentives, patient incentives, or shared physician and patient incentives compared to no incentives on reducing levels of low-density lipoprotein cholesterol (LDL-C) among patients with high cardiovascular risk?
A four-group, multicenter, cluster randomized clinical trial with a 12-month intervention was conducted from 2011 to 2014 in three primary care practices in the northeastern United States. Three hundred and forty eligible primary care physicians (PCPs) were enrolled from a pool of 421. Of 25,627 potentially eligible patients of those PCPs, 1,503 enrolled. Patients ages 18-80 years were eligible if they had a 10-year Framingham Risk Score (FRS) of ≥20%, had coronary artery disease (CAD) equivalents with LDL-C ≥120 mg/dl, or had an FRS of 10-20% with LDL-C ≥140 mg/dl. Investigators were blinded to study group, but participants were not. PCPs were randomly assigned to control, physician incentives, patient incentives, or shared physician-patient incentives. Physicians in the physician incentives group were eligible to receive up to $1,024 per enrolled patient meeting LDL-C goals. Patients in the patient incentives group were eligible for the same amount, distributed through daily lotteries tied to medication adherence. Physicians and patients in the shared incentives group shared these incentives. Physicians and patients in the control group received no incentives tied to outcomes, but all patient participants received up to $355 each for trial participation.
Mean baseline LDL-C in each group was about 160 mg/dl. At 12 months, the shared group LDL-C was 126.4 mg/dl, and in the control group, 136.4 mg/dl. Only patients in the shared physician-patient incentives group achieved reductions in LDL-C levels statistically different from those in the control group (8.5 mg/dl; 95% confidence interval, 3.8-13.3; p = 0.002). For comparison of all four groups, p < 0.001. In post hoc analyses at 12 months, 49% of patients in the shared physician-patient incentives group had achieved their LDL-C goal compared with 40% in physician and patient incentives, and 36% in control (p = 0.03 for comparison of all four groups). There was no change in LDL-C values 3 months after stopping the incentives.
In primary care practices, shared financial incentives for physicians and patients, but not incentives to physicians or patients alone, resulted in a statistically significant difference in reduction of LDL-C levels at 12 months.
The concept of a financial incentive for physician and patients to enhance drug compliance would seem to be an anathema for a health care system regardless of payer. The cost of the physician-patient sharing the incentive was $1,024 for an average of 8 mg/dl reduction or $128 for every 1 mg/dl decrease in LDL-C.
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