Most HMOs Found to Use Pay-for-performance Provider Contracts, Can Medicare Follow Suit?

The current Medicare system may not be amenable to the controversial pay-for-performance mechanism some health care experts want to implement, according to a study in the Nov. 2 New England Journal of Medicine.

As its name suggests, pay-for-performance refers to a system that pays health care providers based on the quality of their services. First author Meredith Rosenthal, HSPH associate professor of health economics and policy; Arnold Epstein, chair of the Department of Health Policy and Management at HSPH; and their colleagues have provided the first comprehensive analysis of the character and prevalence of these programs in the private health care sector across the United States. Their findings indicate that pay-for-performance is in widespread use among HMOs.

Of the 53 percent of HMOs found to have some pay-for-performance functions, the greatest concentration was in the Northeast and West, and a larger proportion existed among nonprofits than for-profits.

The team of researchers looked at 252 HMOs from 41 metropolitan areas around the country between July 2005 and January 2006, a sample that included roughly 91 percent of all HMO participants. They found more than half of the organizations used pay-for-performance in their provider contracts. Of these programs, almost 90 percent had incentive systems focused on individual physicians, while 38 percent also had hospital-based programs. Nearly all programs measured the quality of clinical care. Many also considered information technology and patient satisfaction. Thirty-three percent of physician-oriented incentive programs rewarded only top-ranked physicians, 60 percent established a performance threshold to determine rewards, and 20 percent rewarded improvement.

The concept of pay-for-performance health care has been much debated. Proponents claim financial incentives will motivate hospitals and physicians to provide better care, which will lead to less redundancy and greater cost-efficiency in the long run. On the other hand, opponents point out, measuring the performance levels of doctors is a tricky business; for example, a rigid set of standards might not work uniformly in different regions of the country. Other concerns include the possibility that financial incentives will encourage doctors to selectively care for those patients more likely to achieve positive health outcomes: namely, the healthy and the rich. In general, doctors, insurers, and policy experts have haggled over every hypothetical aspect of the system from how performance should be measured to who exactly should be rewarded and in what manner.

While these debates ensue, the Centers for Medicare and Medicaid Services has moved toward adopting pay-for-performance to fulfill the agenda set forth in the Deficit Reduction Act of 2005, which calls for value-based hospital payments for Medicare patients starting in 2009. According to Epstein’s results, however, Medicare might need to make some basic changes first.

For starters, Medicare patients are not required to select primary care physicians. But programs without PCPs were less likely to implement pay-for-performance programs, presumably because of the difficulty in holding a specific doctor or group accountable for an individual patient’s health. Second, the HMOs in Epstein’s study found practice groups an easier locus of measurement than individual physicians. Consequently, groups were the most common unit of payment. For the most part, however, Medicare does not recognize practice groups as contracting entities. Cost may also be a barrier for Medicare. Many private insurers use rewards greater than 5 percent of payments, a cost some say the public health service cannot afford.

—Jeneen Interlandi

Transmembrane Molecule May Inhibit T Cell Activation

The type I transmembrane glycoprotein CEACAM1, which may be the original member of a 19-gene superfamily in humans, functions as an inhibitory coreceptor in T cells, according to a study in the December Immunity. The findings may have direct implications for the treatment of colitis and many other types of inflammation.

T cell activation relies on more than just T cell receptor–MHC complexing; secondary signals that can either enhance or inhibit T cell function also play an important role. Previous studies have pointed to CEACAM1 (short for carcinoembryonic antigen cell adhesion molecule 1) as a likely candidate in this process, but its in vivo significance and mechanism of action were not established until now.

Richard Blumberg, HMS professor of medicine at Brigham and Women’s Hospital, and his colleagues studied two specific isoforms of CEACAM1, in vitro and in vivo: the 2L and 4L splice variants (named for their number of extracellular Ig domains and their long cytoplasmic tails). For both isoforms, the researchers found that specific overexpression inhibited T cell activation and cytokine production, while conditional deletion increased these T cell activities. Overexpression of CEACAM1-4L led to greater inhibition than an excess of the 2L variant, suggesting that more extracellular domains may be the key to more potent inhibition.

The CEACAM1 glycoproteins appear to be acting via tyrosine-based inhibitory motifs within their cytoplasmic domains and the tyrosine phosphatase SHP1—mutating either of these abrogated the regulatory effect of CEACAM1 on T cells both in vitro and in vivo. Yet deletion of the inhibitory motifs or SHP1 had a greater impact on Th1 cells than on Th2 cells, suggesting that Th1 pathways may be more sensitive to regulation by CEACAM1.

Blumberg’s study suggests that CEACAM1-mediated inhibition is an independent regulatory mechanism that may play as important a role in T cell regulation in vivo as the expression of inhibitory cytokines by regulatory T cells. Although more work needs to be done, this method of T cell inhibition may be a good target for the treatment of colitis and other forms of dysregulated inflammation since overexpression of CEACAM1 prevented naive T cells from inducing colitis or contact hypersensitivity.

—Jeneen Interlandi

Noninvasive Brain Stimulation Holds Promise for Epilepsy

The recurring seizures of epilepsy result from an imbalance of neurotransmitters in the brain or an abnormality in their signaling.

Anti-epileptic drugs are the treatment of choice for the majority of patients. Yet approximately 30 percent of them fail to respond to medication, making it essential to explore other avenues of treatment. A study reported in the October Annals of Neurology by Felipe Fregni, HMS instructor in neurology at Beth Israel Deaconess Medical Center, and colleagues shows that a noninvasive brain stimulation procedure, repetitive transcranial magnetic stimulation (rTMS), induces a significant reduction in the number of epileptic seizures in patients who suffer from refractory epilepsy.

This study was designed as a randomized, double-blind, controlled trial and consolidates differing past opinions about the anti-epileptic potential of rTMS. In it, the researchers assessed rTMS treatment in 21 patients, the majority having a single epileptogenic focus in the cortical area that appeared as a cortical malformation. All of the patients were nonresponsive to medications.

In this treatment, an electromagnetic coil applied to the patient’s scalp is used to deliver repeated, short magnetic pulses, which induce alterations in the electrical activity of the cortex. Patients who received rTMS treatment experienced a 72 percent reduction in the number of seizures for up to two weeks after stimulation. At eight weeks after the procedure, the reduction in the number of seizures was sustained at 58 percent.

Fregni, the lead author of the study, cites the targeted nature of the treatment as being one of its greatest advantages. “An epileptogenic focus in the brain is much like a tumor, since it often exists as an independent entity which is no longer controlled by its neighboring cells. In such a scenario, it is especially important to specifically target the epileptogenic focus without affecting the surrounding healthy tissue.”

The study also evaluated the cognitive functions of the patients following rTMS. The researchers observed a marked improvement in focused attention, decision-making, social interaction, and energy levels after treatment. Although these effects were not as long lasting as the duration of the low-seizure or seizure-free period, Fregni said that they resulted in a remarkable transformation in the patients’ demeanor.

Studies are under way on rTMS as a treatment for epilepsy using a larger number of patients. This research will aim to test the reproducibility of the current results while examining ways to make the positive outcomes of rTMS more sustainable. Fregni commented, “I am optimistic that these studies combined with the latest neuroimaging techniques will promote a widespread use of noninvasive brain stimulation for treatment of neurological disorders.”

—Amita Joshi

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