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Financial Incentives and Education Do Not Help Patients Better Manage Hypertension or Reduce Racial and Ethnic Disparities in Management of the Disease


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Summary

Using a $258,500 grant from Robert Wood Johnson Foundation’s Finding Answers: Disparities Research for Change program, CIGNA Healthcare offered a small financial incentive and educational materials and tools to patients with hypertension and prehypertension (i.e., elevated systolic and/or diastolic blood pressure that is not high enough to be classified as hypertension). The goal was to encourage these individuals to visit their doctor and better manage their blood pressure on an ongoing basis. Compared to usual care and the use of educational materials alone, the combination of the incentive and education led to a small, short-lived increase in physician visits, but had no effect on blood pressure control for the target population as a whole or on racial and ethnic disparities in management and control of hypertension. It did lead to improvements in blood pressure control among the subset of patients with prehypertension.
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Developing Organizations

CIGNA; RAND Health
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Date First Implemented

2010
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Patient Population

Vulnerable Populations > Racial minoritiesend pp

Problem Addressed

Uncontrolled hypertension is common, especially among African Americans, and often leads to significant health problems. Physicians can play a critical role in helping patients manage their hypertension, yet many hypertensive patients do not regularly visit a doctor.
  • Many with uncontrolled hypertension: Nearly 1 in 3 American adults—72 million individuals—have high blood pressure (defined as blood pressure above 140/90 mm Hg for patients without diabetes); approximately 43 percent of them do not have the condition under control.1,2
  • Greater risk for African Americans: African-American adults are 40 percent more likely to have high blood pressure than non-Hispanic white adults, and 10 percent less likely to have the condition under control.3
  • Leading to significant health problems: Hypertension is a major risk factor for cardiovascular diseases, including stroke, myocardial infarction, aortic aneurysm, and peripheral arterial disease, and it can also cause chronic kidney disease.4
  • Unrealized potential of regular physician visits: Physicians can play a critical role in helping hypertensive patients by evaluating and revising medication regimens and discussing and encouraging potential lifestyle changes. Yet a meaningful proportion of hypertensive patients do not regularly see their doctor. For example, before introduction of this program by CIGNA, roughly 15 percent of members with hypertension had not seen a doctor in the last year. Nationally, approximately 30 percent of patients with hypertension do not take medication to treat their condition.2

What They Did

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Description of the Innovative Activity

In a 24-month study, CIGNA Healthcare offered a small financial incentive and brief educational materials and tools to 6,000 hypertensive and prehypertensive patients in Maryland; Virginia; and Washington, D.C., with the goal of encouraging these individuals to visit their doctor and better manage their blood pressure. Key elements included the following:
  • Small financial incentive to see doctor: Patients who had hypertension or prehypertension (defined as systolic blood pressure between 130 and 139 mm Hg and/or diastolic blood pressure between 80 and 89 mm/Hg) received a one-time financial incentive of $15, in the form of an American Express gift card, for completing a hypertension visit with a provider. The patient received the gift card once a claim had been filed, indicating the visit had been completed.
  • Educational materials and tools: Patients received a letter that outlined the need to manage hypertension on an ongoing basis and the important role of medication and lifestyle changes in doing so. They also received a pocket tool for recording blood pressure.
  • Comparison groups: Two other groups of hypertensive and prehypertensive patients, each numbering 6,000, participated in the study. One group received educational materials only and the other received usual care.

Did It Work?

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Results

Compared to usual care and distribution of the educational materials alone, the combination of the incentive and education led to a small, short-lived increase in physician visits, but had no effect on blood pressure control for the population as a whole or on racial and ethnic disparities in management and control of hypertension. It did lead to improvements in blood pressure control among those with prehypertension.
  • Small, short-lived increase in physician visits: The financial incentive and educational materials generated a modest, short-term increase in physician visits, especially among those who had not seen a physician in more than 1 year. Three months after the intervention, 33.8 percent of the 6,000 patients receiving both the incentive and education had visited a physician, compared to 32.7 percent of the group receiving just education (also 6,000 patients) and 31.1 percent of those receiving usual care (also 6,000 patients). Although this difference was small, the 2.7-percentage point gap—33.8 percent versus 31.1 percent—met the test of statistical significance. After 6 months, the difference in visit rates had diminished (but remained statistically significant), and after 1 year there was no meaningful difference in visits rates across the groups.5
  • No impact on blood pressure control, except among subset with prehypertension: The combination of financial incentives and educational materials did not lead to an improvement in blood pressure control across the entire population evaluated. Among those with prehypertension, the program generated significant, sustained reductions in systolic blood pressure.5
  • No impact on racial and ethnic disparities: Formal tests to compare the effectiveness of the initiative across racial and ethnic groups found that it did not have a differential impact on minorities in influencing either physician visits or blood pressure control.5

What They Learned

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  • Target patients with some level of control: As noted, the program had a positive impact in helping those with prehypertension attain a greater level of blood pressure control.
  • Tie incentives closely to condition: Feedback from patients who participated in the trial suggests that an incentive tied more closely to hypertension, such as a discount on the purchase of a blood pressure cuff or a reduction in copayments for medications, would have been more effective than a gift card in motivating behavioral change.
  • Make educational materials emphatic: Patients noted that the educational materials did not adequately warn about the dangers of uncontrolled hypertension, and felt they should include a clearer "call to action" about what patients should do to better control hypertension.
  • Consider using program as way to encourage appointments, start dialogue: As noted, the program appeared to have a modest, short-term impact on physician visits, especially among those who had not seen a doctor in more than 1 year. In addition, physicians noted that some patients brought the educational materials to their appointments, using them as a way to start a dialogue about their condition.

More Information

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Contact the Innovator

Kathryn Pierce
Director, Clinical Initiatives
CIGNA
3500 Piedmont Road NE
Atlanta, GA 30305
(404) 377-5503
E-mail: kathryn.pierce@cigna.com

Innovator Disclosures

Ms. Pierce reported that the Robert Wood Johnson Foundation paid travel expenses for her to attend two conferences and serve as a panelist (although she refused the offer of an honorarium); in addition, information on funders is available in the Funding Section.

References/Related Articles

National Health Plan Collaborative. 2013 Leadership Roundtable; 2013 Feb 13; Washington, D.C.

Martin L, Acosta J, Ruder T, et al. Patient incentives to motivate doctor visits and reduce hypertension disparities. RAND Health/CIGNA Healthcare, 2011. Available at: http://www.rand.org/pubs/technical_reports/TR1167.html.

Footnotes

1 National Center for Health Statistics. Table 63. Selected health conditions and risk factors: United States, selected years 1988-1994 through 2009-2010. In: Health, United States, 2012: with special feature on emergency care. Hyattsville (MD): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/data/hus/hus12.pdf (If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).
2 Ostchega Y, Yoon SS, Hughes J, et al. Hypertension awareness, treatment and control—continued disparities in adults: United States, 2005-2006. NCHS Data Brief. 2008;(3):1-8. [PubMed]
3 National Center for Health Statistics. Table 2. Age-adjusted percentages of selected circulatory diseases among persons aged 18 years and over, by selected characteristics: United States, 2010. In: Summary health statistics for U.S. adults: national health interview survey, 2010. Hyattsville (MD): U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. Available at: http://www.cdc.gov/nchs/data/series/sr_10/sr10_252.pdf.
4 Sennett C. Implementing the new HEDIS hypertension performance measure. Manag Care. 2000;9(4):2-17. [PubMed]
5 Martin L, Acosta J, Ruder T, et al. Patient incentives to motivate doctor visits and reduce hypertension disparities. RAND Health/CIGNA Healthcare, 2011. Available at: http://www.rand.org/pubs/technical_reports/TR1167.html.
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Original publication: January 15, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: January 15, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.

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