Effect of Pay-for-Performance Incentives on Quality of Care in Small Practices With Electronic Health Records: A Randomized Trial

Study Questions:

What is the impact of pay-for-performance (P4P) on cardiovascular preventive care processes and outcomes among small practices (1-10 clinicians) participating in the voluntary New York City Department of Health and Mental Hygiene Primary Care Information Project (PCIP)?


This was a cluster-randomized trial of small primary care clinics. Participating clinics were randomized to an intervention group receiving quarterly reports and financial incentives or a control group receiving only quarterly reports. The following care processes and outcomes were targeted: aspirin or antithrombotic prescription, blood pressure control, cholesterol control, and smoking cessation. Incentivized clinics were paid for each patient whose care met the performance criteria (higher payments were given for patients with comorbidities, who had Medicaid insurance, or who were uninsured). The primary outcome of interest was the differences between the incentive and control groups in the proportion of patients achieving these measures.


Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription (12.0% vs. 6.1%, difference: 6.0%; 95% confidence interval [CI], 2.2%-9.7%; p = 0.001 for interaction term), blood pressure control (no comorbidities: 9.7% vs. 4.3%, difference: 5.5%; 95% CI, 1.6%-9.3%; p = 0.01 for interaction term), and smoking cessation interventions (12.4% vs. 7.7%, difference: 4.7%; 95% CI, -0.3% to 9.6%; p = 0.02 for interaction term). Baseline performance for cholesterol control was more than 90% in both intervention and control groups, and there was no statistically significant difference between groups on cholesterol control following the intervention. The range of payments to clinics was $600 to $100,000 (median, $9,900).


The authors concluded that a P4P incentive program led to modest improvements in cardiovascular care processes and outcomes among small electronic health record–enabled clinics.


This study is an important contribution to existing P4P literature in that this is the first clinical trial to focus specifically on independent small-group practices. As the authors point out, 82% of US physicians practice in groups of fewer than 10 clinicians. The current analysis may help dispel some concerns that such small group practices may not be able to respond to P4P incentives. Further research is needed to characterize the durability of the improved outcomes seen with P4P incentive programs.

Clinical Topics: Dyslipidemia, Lipid Metabolism, Nonstatins

Keywords: New York City, Medicaid, Comorbidity, Blood Pressure, Physician Incentive Plans, Electronic Health Records, Salaries and Fringe Benefits, Cholesterol, Medically Uninsured, Quality Assurance, Health Care, Confidence Intervals, United States, Primary Health Care, Smoking Cessation, Group Practice

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