Circulation: Evidence-based incentives, not P4P, key to healthcare reform

"Evidence-based reimbursement," or structuring physician payment incentives around empirical evidence of clinical benefit, would improve the quality and reduce the cost of healthcare, according to a commentary by two cardiologists published in the March issue of Circulation: Cardiovascular Quality and Outcomes.

For example, about 500,000 U.S. patients suffering from mild chest pain due to coronary artery disease (CAD) undergo balloon angioplasty or PCI annually, a procedure that costs approximately $20,000 per patient, for a total U.S. expenditure of $10 billion a year. However, studies suggest that 10 to 20 percent of PCI patients are asymptomatic, only 50 percent have undergone a stress test to determine the severity of their disease and as many as 30 percent are not taking prescription heart medications that, for patients with mild CAD, could be just as effective as PCI.

George Diamond, MD, a senior research scientist, emeritus, and Sanjay Kaul, MD, director of the cardiology fellowship training program and director of the Vascular Physiology and Thrombosis Research Laboratory at the Cedars-Sinai Heart Institute in Los Angeles, cited the COURAGE (Clinical Outcomes Utilizing Revascularization and Aggressive drug Evaluation) trial, which followed 2,000 patients with mild to moderate chronic stable angina. All patients received optimal medical therapy, and half of the patients also underwent angioplasty. The patients were followed for 4.6 years, but there was no significant difference between the groups in the mortality rate.

As an example of evidence-based financial incentives, Diamond and Kaul proposed that physicians of the patients who undergo PCI be paid on a sliding scale, from $8,000 to $24,000, with the highest payments going to the physicians of patients with the most severe symptoms because the sickest patients receive the most benefit from the procedure.

"A lot of care isn't tied directly to proof of patient benefit in clinical trials," Diamond said. "It's not that the care is wrong. It's not documented to be of value. And if it's not documented to be of value, then it should be worth less. The purpose is not to deny anybody of healthcare, but rather to funnel them to the best proven care alternatives."

Diamond and Kaul suggested that empirical data could be used to determine how much physicians would be paid by Medicare and private insurers for performing specific procedures. They said that they hope to prompt a discussion of "evidence-based reimbursement incentives" rather than "pay for performance" among the public and policy makers.