Objective: To describe the impact of a commercial insurer's financial incentives to hospitals in conjunction with collaboration with the American Heart Association (AHA) to accelerate implementation of Get With The Guidelines–Coronary Artery Disease (GWTG-CAD), a quality improvement program to rapidly improve cardiovascular secondary prevention in hospitalized patients.
Study Design: Observational assessment of quality improvement program participation and implementation in response to financial incentives.
Methods: The study population included all hospitals that participated with the Hawaii Medical Service Association (HMSA, Blue Cross Blue Shield of Hawaii) Hospital Quality and Service Recognition Program and had more than 30 annual admissions for acute coronary artery disease. These 13 hospitals were given encouragement and financial incentives to implement GWTG-CAD. Financial incentives were determined by a prorated amount of the total HMSA hospital reimbursement for all acute services, as part of a more comprehensive hospital "pay for performance" program.
Results: Incentives to 10 of 13 eligible hospitals included reimbursement for half the annual cost of the AHA Patient Management Tool. In addition, HMSA's pay for performance programthe Hospital Quality and Service Recognition Programdistributed monetary awards totaling $354 883, based on points awarded for GWTG-CAD workshop attendance documentation (10 hospitals), recognition by the AHA as a GWTG-CAD hospital, and attainment of 85% adherence to the GWTG-CAD performance measures (4 hospitals).
Conclusions: Community-based promotion of GWTG-CAD and financial incentives provided by a commercial insurer resulted in the rapid implementation of a secondary prevention program for coronary artery disease in most hospitals in the State of Hawaii within a single year.
(Am J Manag Care. 2004;10:501-504)
The American Heart Association (AHA) and The
American College of Cardiology have established
cardiovascular secondary prevention
guidelines recommending several behavioral and pharmacologic
interventions for hospitals to reduce the
risk of recurrent cardiac events.1 When these interventions
are implemented in a hospital, recurrent
events have been markedly reduced.2-4 Despite this
evidence, national studies, as well as Hawaii Medical
Service Association (HMSA) claims data, reveal that
secondary prevention interventions including the use
of aspirin, β-blockers, angiotensin-converting enzyme
inhibitors, lipid-lowering agents, and smoking cessation
counseling are applied inconsistently in hospital
and outpatient settings.5-9 Barriers to implementation
of these interventions include lack of knowledge,
financial resources, or time; poor communication;
conflicting organizational objectives; and lack of timely
To help hospitals close this gap, the AHA designed and
implemented a hospital-based program called Get With
The Guidelines–Coronary Artery Disease (GWTG-CAD)
using a collaborative learning model11 and an Internet-based
Patient Management Tool for data collection,
reporting, and decision support.12 The components of the
program have been described previously and include the
development of community-based consensus, a series of
collaborative learning sessions, and support of collaborative
problem solving between sessions using conference
calls, e-mail, and AHA staff facilitation.13
The major costs for a hospital to implement the
GWTG-CAD program are the personnel costs to attend
meetings, collect data, and create meaningful system
change to improve care. As a result, lack of financial
incentives, cited as a common barrier to adoption of
quality improvement initiatives, is likely a barrier for
GWTG-CAD as well.10
The goal of this study was to determine how well
financial incentives to hospitals translated into compliance
with the Hawaii GWTG-CAD program processes
by enabling hospitals to build the necessary
Hospitals were awarded points as part of a payerbased
financial incentives program for various activities
in GWTG-CAD (Table 1). These activities
included the building of the hospital team, attending
the collaborative meetings, and using the Patient
Management Tool to submit data, as well as improving
guideline adherence levels for eligible patients. Most
of the incentive points were provided for process
measures during the first year as infrastructure was
being developed. Participation in GWTG-CAD for the
development of this infrastructure has been shown to
lead to significantly increased performance of acute
care and secondary prevention measures.14,15 Hospital
participation and measures of system change including
clinical champion identification, multidisciplinary
team creation, baseline and follow-up data collection,
and the use of preprinted orders and protocols were
tracked. GWTG-CAD hospital recognition based on
these process measures, as well as adherence to the
GWTG-CAD measures, were also tracked as criteria for
incentive payments. Thirteen hospitals that provided
care for HMSA patients were eligible for the incentive
In February 2002, The AHA convened a stakeholder
meeting for GWTG-CAD, which including key Hawaii
organizations and opinion leaders. The HMSA was a
stakeholder collaborating with the AHA to provide
encouragement and incentives to hospitals for meaningful
participation in the program. These activities
included cosponsorship of meetings, hospital recruitment,
and reimbursement to participating hospitals for
half of the yearly $900 fee for use of the Patient
The financial incentive program was announced at
the first hospital workshop, reviewed in subsequent
workshops, and communicated directly to hospital chief
executive officers and chief financial officers in other
meetings and by written correspondence. Scoring for
the initial year made 140 points of the 1670 total
potential points in the Hospital Quality and Service
Recognition Program available to hospitals for GWTGCAD;
60 of the 140
potential points were
awarded. In some
cases hospitals met
the point criteria for
incentives after the
deadline for the
incentive program or
failed to provide documentation
activities as required;
these hospitals did
not receive incentives
for these elements. A
maximum of 10 points
was available to each
hospital. Points earned
and financial incentives
paid to each hospital
in Table 2.
points resulted in
$354 883 awarded.
This modest amount
of dollars assigned to
with a high level of
85% of Hawaii's eligible hospitals. Interviews with
hospital administrators indicated
that the incentives were used to
support in the hospital quality improvement
staff salaries and travel
costs for hospital staff to attend
GWTG-CAD workshops and related
In workshops and conference
calls, hospitals shared solutions
to program implementation barriers,
leading to substantial
changes in the systems of
care.They continue to collect
patient data and use the decision
support, communication tools,
and reminders that are embedded
in the Patient Management
Tool.12 Thus far more than 2000
patients have been included in
this program in Hawaii.
In this study, we demonstrated
that by providing financial
incentives, the Hawaii GWTGCAD
program was able to secure active institutional
participation in implementation of system changes to
support more uniform adoption of cardiovascular
Based on previously published outcome data2-4 and
the progress of other GWTG hospitals in improving
guideline adherence,14,15 a significant and measurable
improvement in secondary prevention of coronary
artery disease in Hawaii is anticipated. Factors that correlate
with improvement including multidisciplinary
teams, collaborative support, and the use of the Patient
Management Tool for data, reporting, and decision support
are now in place. The GWTG-CAD program has
become the standard to improve cardiovascular care
and is now being used in all but 1 hospital in Hawaii.
The full participation of more than 85% of hospitals is
much higher than would be predicted by models of "diffusion
of innovation" in healthcare.16,17 Typically such
programs attract early adopters and the early majority
that would account for somewhat less than half of the
hospitals in a market. In fact, 30% to 50% penetration of
GWTG-CAD has been commonly seen in most markets.
Involvement of more than 85% would suggest significant
engagement of the late majority as well. This finding
suggests that the presence of financial incentives tied to
the steps of participation may play an important role in
speeding the adoption of innovative programs such as
This report documents the first, important steps to
reach the goal of improved patient outcomes. We
believe that financial incentives geared toward an established
and successful process to improve care is a novel
and important approach as the healthcare system
begins to explore the alignment of financial incentives,
generally referred to as "pay for performance." Perhaps
this effort to help hospitals build the critical infrastructure
in a larger proportion of hospitals in Hawaii than is
commonly seen could play a role in accelerating the
transformational change called for by the Institute of
From the Hawaii Medical Service Association, Honolulu, Hawaii (JTB, JNO); American Heart Association, Irvine, Calif (PAT); MassPRO, Inc, Waltham, Mass (KAL); and Brown University School of Medicine, Providence, RI (KAL).
This work was funded by the Hawaii Medical Service Association. The Centers for Medicare & Medicaid Services provided resources for program development and analysis under contract 500-02-MA03. Get With The Guidelines–Coronary Artery Disease (GWTGCAD) is sponsored in part by an unrestricted educational grant from Merck.
The conclusions and interpretation of results are the sole responsibility of the authors and do not necessarily reflect the position or policy of the US Government.
Address correspondence to: John T. Berthiaume, MD, Hawaii Medical Service Association, 818 Keeaumoku Street, Honolulu, HI 96814. E-mail:firstname.lastname@example.org.
1. Smith SC Jr, Blair SN, Bonow RO, et al. AHA/ACC scientific statement: AHA/ACC guidelines for preventing heart attack and death in patients with atherosclerotic cardiovascular disease: 2001 update: a statement for healthcare professionals from the American Heart Association and the American College of Cardiology. Circulation. 2001;104:1577-1579.
2. Marciniak TA, Ellerbeck EF, Radford MJ, et al. Improving the quality of care for Medicare patients with acute myocardial infarction: results from the Cooperative Cardiovascular Project. JAMA. 1998;279:1351-1357.
3. Fonarow GC, Gawlinsi A, Moughrabi S, Tillisch JH. Improved treatment of coronary heart disease by implementation of a cardiac hospitalization atherosclerosis management program (CHAMP). Am J Cardiol. 2001;87:819-822.
4. Peterson ED, Parsons LS, Pollack CV, Newby LK, Littrel KA. Variation in AMI care across 1085 US hospitals and its association with hospital mortality rates. Presented at: American Heart Association Scientific Sessions 2002; November 17–20, 2002; Chicago, Ill. Abstract 103093.
5. Pearson TA, Peters TD, Feury D, et al. The American College of Cardiology Evaluation of Preventative Therapeutics (ACCEPT) study: attainment goals for comprehensive risk reduction in patients with coronary disease in the US [abstract]. J Am Coll Cardiol. 1998;31(suppl):186A. Abstract 838-1.
6. Jencks SF, Huff ED, Cuerdon T. Change in the quality of care delivered to Medicare beneficiaries, 1998-1999 to 2000-2001 [published correction appears in JAMA. 2002;289:2649]. JAMA. 2003;289:305-312.
7. Pearson TA, Laurora I, Chu H, Kafonek S. The lipid treatment assessment project (L-TAP): a multicenter survey to evaluate the percentages of dyslipidemic patients receiving lipid-lowering therapy and achieving low-density lipoprotein cholesterol goals. Arch Intern Med. 2000;160:459-467.
8. Pearson TA, Peters TD. The treatment gap in coronary artery disease and heart failure: community standards and the post-discharge patient. Am J Cardiol.1997;80:45H-52H.
9. Sueta CA, Chowdhury M, Boccuzzi SJ, et al. Analysis of the degree of undertreatment of hyperlipidemia and congestive heart failure secondary to coronary artery disease [published correction appears in Am J Cardiol. 1999;84:1143]. Am J Cardiol. 1999;83:1303-1307.
10. Cabana MD, Rand CS, Powe NR, et al. Why don't physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999;282:1458-1465.
11. Kilo CM. Improving care through collaboration. Pediatrics. 1999;103(suppl E):384-393.
12. LaBresh KA, Glicklich R, Liljestrand J, Peto R, Ellrodt AG. Using "get with the guidelines" to improve cardiovascular secondary prevention. Jt Comm J Qual Saf. 2003;29:539-550.
13. LaBresh KA, Tyler PA. A collaborative model for hospital-based cardiovascular secondary prevention. Qual Manag Health Care. 2003;12:20-27.
14. LaBresh KA, Ellrodt AG, Glicklich R, Liljestrand J, Peto R. Get with the guidelines for cardiovascular secondary prevention: pilot results. Arch Intern Med. 2004;164:203-209.
15. LaBresh KA, Fonarow G, Ellrodt AG, et al. Get With The Guidelines improves cardiovascular care in hospitalized patients with CAD. Circulation. 2003;108(suppl 4):722.
16. Rogers EM. Diffusion of Innovations. 4th ed. New York: The Free Press; 1995.
17. Berwick DM. Disseminating innovations in health care. JAMA. 2003;289:1969-1975.
18. Institute of Medicine, Committee on Quality Health Care in America. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.