Evidence-based financial incentives for healthcare reform: putting it together.

“Bit by bit, putting it together Piece by piece, only way to make a work of art Every moment makes a contribution Every little detail plays a part. Having just a vision’s no solution, Everything depends on execution Putting it together, that’s what counts!” — —Stephen Sondheim Once, on hearing a colleague claim that the details of his new theory remained to be sketched in, Nobel laureate Wolfgang Pauli drew a crude rectangle on the chalkboard, and said, “Here is the proof that I am as great an artist as Rembrandt; only the details remain to be sketched in.” Current proposals for healthcare reform have been similarly described as rough “…sketches rather than finished portraits, with many important details yet to be revealed.”1 Each, for example, promises to link payment incentives to outcomes and performance; but none provide any specifics regarding the substance of these incentives. In this essay, we describe a specific strategy for structuring these incentives around the existing empirical evidence of clinical benefit, and outline its potential for improving the quality and reducing the cost of health care. We term this approach evidence-based reimbursement. ### Evidence-Based Reimbursement Versus Pay for Performance Some might see a surface similarity between the idea of evidence-based reimbursement and so-called “pay-for-performance” strategies, which have been widely adopted (in various forms) as models for provider-payment healthcare reform.2,3 They are not the same. In general, pay-for-performance strategies seek to reward physicians for meeting certain predefined benchmarks of quality health care. These benchmarks are usually defined in terms of established guidelines or ad hoc criteria for the detection and appropriate management of common clinical conditions such as hypertension and hyperlipidemia. In its simplest implementation, physicians who adhere to these benchmarks are rewarded at annual intervals with a monetary bonus. The American College of Cardiology has defined the following 12 desiderata …