Using Pay for Performance to Promote Smoking Cessation

This randomized, unblinded clinical trial sought to determine if a financial incentive program could encourage clinicians to refer smokers to a Tobacco Quit Line. The unit of study was the individual health clinic; all clinics were a part of a Minnesota physicians’ network.

Payers provided financial bonuses ($5,000 if at least 50 patients received referrals and an additional $25 per patient above that threshold) to individual clinics in the intervention group. Clinics in the control group received no financial incentive. Individual clinicians did not receive any direct financial incentives.

Results demonstrate that clinics in the intervention group (i.e. those with financial incentives) referred a significantly higher proportion of smokers to the Quit Line (11.4% vs. 4.2%, p=0.001). The effect of incentives was greatest in clinics which had not engaged in quality improvement measures in the past. Clinics which had been active participants in quality improvement projects did not demonstrate any significant effect from the financial incentive.

Comment:

This study demonstrates the beneficial effect that indirect financial incentives have for changing clinician behavior. However, it appears that such pay for performance (P4P) measures have diminishing returns. For those clinics already actively engaged in quality improvement programs, additional financial incentives did not result in improved outcomes. Thus, future P4P initiatives ought to focus efforts on promoting quality improvement among poor performers and not simply rewarding those already doing well.

An additional consideration for designers of P4P programs are costs affiliated with financial incentives. Bonuses totaled $95,733 resulting in estimated marginal costs of the intervention of $83 per additional referral and $300 per additional smoker enrolled in the Quit Line program. According to the authors of the study, for each smoker treated, a health care savings of approximately $500 can be expected. The clinical and cost effectiveness of this and other P4P programs needs continued evaluation.

Arch Int Med 2008 (168) 18: 1993-1999.

by

Cedric K. Dark, MD, MPH