Changing intensivists’ behaviors: A challenge in need of new solutions

To promote higher-quality health care, health systems are increasingly using financial incentives to motivate physicians to more commonly provide certain types of care or less commonly provide others. The Centers for Medicare and Medicaid Services first formalized such “pay for performance” (P4P) programs in 2003, with the Premier Hospital Quality Incentive Demonstration, a program of voluntary hospital participation that rewarded top-quality scores and large improvements and penalized bottom performance. Since then, Centers for Medicare and Medicaid Services, private payers, and hospitals have introduced hundreds of value-based reimbursement programs. In March 2015, the Department of Health and Human Services partnered with public, private, and nonprofit stakeholders to launch the Health Care Payment Learning and Action Network. This group recently reported that 25% of health care payments incorporate a P4P model, and Department of Health and Human Services has set a goal of including P4P elements in 50% of all its payments by the end of 2018.

Despite this growing use, data regarding the success of P4P programs have been mixed. For example, an analysis of the Premier program demonstrated no long-term improvement in 30-day mortality, suggesting that its performance measures may not accurately reflect quality. Furthermore, concerns about unintended consequences of P4P have surfaced, such as denying services to high-risk patients and amplifying health care disparities. Given dramatic variation in care provision among intensive care units (ICUs) and among intensivists within ICUs, it is important to determine whether P4P can successfully improve critical care quality.

In this issue of the Journal, Barbash and colleagues add considerably to a nascent evidence base regarding P4P in the ICU. Like at least two prior studies, the authors use a pre–post design to analyze physician-targeted financial incentives to promote evidence-based ICU processes. Unlike prior analyses of incentives to reduce albumin utilization and ordering of arterial blood gases, chest X-rays, and blood transfusions, which primarily reduce costs, Barbash and colleagues examined incentives to promote spontaneous breathing trials (SBTs) among eligible mechanically ventilated patients, which may reduce duration of mechanical ventilation and other adverse clinical outcomes.