Evaluating the Consequences of a Hypertension Management Incentive.

IMPORTANCE

Quality metrics with financial incentives are widely used, but their impact on clinical care and patient health remains challenging to isolate.

OBJECTIVE

To evaluate the association of a physician-facing quality metric and financial incentive for hypertension control (blood pressure <140/90 mm Hg) with clinical decisions and health outcomes.

DESIGN, SETTING, AND

PARTICIPANTS

This quasi-experimental difference-in-differences study in a large US health system compared changes in outcomes at practices that did vs those that did not adopt the financial incentive before (2021) vs after (2022-2023) adoption. Participants included patients with previously diagnosed hypertension, aged 18 to 85 years, with encounters at eligible primary care practices. Data were analyzed from January 2024 to September 2025.

EXPOSURES: Patient exposure to the financial incentive was determined by which practice delivered their care.

MAIN OUTCOMES AND MEASURES: Initial and final systolic blood pressure at the primary care encounter and number of measurements, antihypertensive prescriptions and dose adjustments, and hospitalizations for incident stroke or acute coronary syndrome (ACS).

RESULTS

The study included 334 364 patients with hypertension (mean [SD] age, 64.9 [12.6] years; 53.3% female) and their 770 907 encounters at 103 primary care practices. In January 2022, the hypertension control financial incentive was introduced in physician contracts for 63 of these practices. In the overall population of patients with hypertension, the financial incentive was associated with an increased probability of blood pressure remeasurement (by 1.9 [95% CI, 0.7-3.1] percentage points [pp]; P = .002) with no statistically significant change in hypertension control, medication outcomes, or cardiovascular hospitalizations. For the subgroup of patients with marginally high blood pressure (defined as initial systolic blood pressure of 140-145 mm Hg), the financial incentive was associated with an increased probability (by 4.1 [95% CI, 2.1-6.0] pp; P < .001) that blood pressure was documented as controlled, subsequent to an increased probability of blood pressure remeasurement (by 5.6 [95% CI, 2.9-8.3] pp; P < .001). The probability of an existing antihypertensive medication dose being increased was reduced (-1.1 [95% CI, -2.0 to -3.0] pp; P = .01), and the 3-month risk of hospitalization for stroke or ACS increased (by 0.25 [95% CI, 0.07-0.44] pp; P = .005), with excess risk growing to 0.52 pp (95% CI, 0.17-0.87 pp; P = .008) pp at 1 year.

CONCLUSIONS AND RELEVANCE: This study's findings suggest that the addition a quality metric and financial incentive to physicians' contracts in a large health system had little impact on measured outcomes in the overall population of patients with hypertension. For patients with marginally high blood pressure, the incentive was associated with increased documented hypertension control because of selective remeasurement of blood pressure, decreased medication adjustments, and increased cardiovascular hospitalizations.