Hospitals that have been under financial incentives for more than a decade do not have lower patient mortality compared with hospitals that have been under financial incentives for less than 3 years, according to data published in the British Medical Journal.

Researchers from the Harvard T.H. Chan School of Public Health in Cambridge, Massachusetts, conducted an observational study of 1189 hospitals in the United States, including 1,371,364 participants aged 65 years or older. The study included 214 “early adopter” hospitals that volunteered to be under financial incentives for more than a decade as part of the Premier Hospital Quality Incentive Demonstration and 975 “late adopter” hospitals that were under financial incentives for less than 3 years as part of the Hospital Value-Based Purchasing program.

The results showed that early adopters started from a slightly higher baseline of clinical process scores compared with late adopters (92 vs 90). Both groups reached a clinical process “ceiling” score of 98 a decade later.

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At baseline, the mortality rate for early and late adopters was 14.9% and 14.8%, respectively, in the fourth quarter of 2003. However, the mortality rate reduced to 9.9% for both groups in the fourth quarter of 2013. The researchers note that there were no noticeable differences in mortality reductions between early and late adopters during the pre-Hospital Value-Based Purchasing period (percentage difference, −0.02%; 95% CI, −0.06% to 0.02%) and the Hospital Value-Based Purchasing period (percentage difference, 0.02%; 95% CI, −0.02% to 0.07%).

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The investigators note that the results may not be generalized to the general population, as the study only included patients older than 65 years. In addition, the investigators note that it is difficult to determine the effect of pay-for-performance incentives, given the other interventions currently being implemented by the Centers for Medicare & Medicaid Services.

“Given the growing worldwide interest in pay for performance programs and the unclear American health policy agenda,” the authors noted, “these findings should be considered by policymakers when assuming that programs like these simply need more time to have a meaningful effect.”


Bonfrer I, Figueroa JF, Zheng J, Orav EJ, Jha AK. Impact of financial incentives on early and late adopters among US hospitals: observational study [published online January 4, 2018]. BMJ. doi: 10.1136/bmj.j5622