The American Journal of Managed Care
July 2004 - Part 2
Volume 10
Issue 7 Pt 2

Aligning Financial Incentives With "Get With The Guidelines" to Improve Cardiovascular Care

Objective: To describe the impact of a commercial insurer'sfinancial incentives to hospitals in conjunction with collaborationwith the American Heart Association (AHA) to accelerate implementationof Get With The Guidelines–Coronary Artery Disease(GWTG-CAD), a quality improvement program to rapidly improvecardiovascular secondary prevention in hospitalized patients.

Study Design: Observational assessment of quality improvementprogram participation and implementation in response tofinancial incentives.

Methods: The study population included all hospitals that participatedwith the Hawaii Medical Service Association (HMSA, BlueCross Blue Shield of Hawaii) Hospital Quality and Service RecognitionProgram and had more than 30 annual admissions for acutecoronary artery disease. These 13 hospitals were given encouragementand financial incentives to implement GWTG-CAD. Financialincentives were determined by a prorated amount of the total HMSAhospital reimbursement for all acute services, as part of a more comprehensivehospital "pay for performance" program.

Results: Incentives to 10 of 13 eligible hospitals included reimbursementfor half the annual cost of the AHA Patient ManagementTool. In addition, HMSA's pay for performance program–theHospital Quality and Service Recognition Program–distributed monetaryawards totaling $354 883, based on points awarded forGWTG-CAD workshop attendance documentation (10 hospitals),recognition by the AHA as a GWTG-CAD hospital, and attainmentof 85% adherence to the GWTG-CAD performance measures (4hospitals).

Conclusions: Community-based promotion of GWTG-CAD andfinancial incentives provided by a commercial insurer resulted inthe rapid implementation of a secondary prevention program forcoronary artery disease in most hospitals in the State of Hawaiiwithin a single year.

(Am J Manag Care. 2004;10:501-504)

The American Heart Association (AHA) and TheAmerican College of Cardiology have establishedcardiovascular secondary preventionguidelines recommending several behavioral and pharmacologicinterventions for hospitals to reduce therisk of recurrent cardiac events.1 When these interventionsare implemented in a hospital, recurrentevents have been markedly reduced.2-4 Despite thisevidence, national studies, as well as Hawaii MedicalService Association (HMSA) claims data, reveal thatsecondary prevention interventions including the useof aspirin, β-blockers, angiotensin-converting enzymeinhibitors, lipid-lowering agents, and smoking cessationcounseling are applied inconsistently in hospitaland outpatient settings.5-9 Barriers to implementationof these interventions include lack of knowledge,financial resources, or time; poor communication;conflicting organizational objectives; and lack of timelydata feedback.10

To help hospitals close this gap, the AHA designed andimplemented a hospital-based program called Get WithThe Guidelines—Coronary Artery Disease (GWTG-CAD)using a collaborative learning model11 and an Internet-basedPatient Management Tool for data collection,reporting, and decision support.12 The components of theprogram have been described previously and include thedevelopment of community-based consensus, a series ofcollaborative learning sessions, and support of collaborativeproblem solving between sessions using conferencecalls, e-mail, and AHA staff facilitation.13

The major costs for a hospital to implement theGWTG-CAD program are the personnel costs to attendmeetings, collect data, and create meaningful systemchange to improve care. As a result, lack of financialincentives, cited as a common barrier to adoption ofquality improvement initiatives, is likely a barrier forGWTG-CAD as well.10

The goal of this study was to determine how wellfinancial incentives to hospitals translated into compliancewith the Hawaii GWTG-CAD program processesby enabling hospitals to build the necessaryinfrastructure.


Hospitals were awarded points as part of a payerbasedfinancial incentives program for various activitiesin GWTG-CAD (Table 1). These activitiesincluded the building of the hospital team, attendingthe collaborative meetings, and using the PatientManagement Tool to submit data, as well as improvingguideline adherence levels for eligible patients. Mostof the incentive points were provided for processmeasures during the first year as infrastructure wasbeing developed. Participation in GWTG-CAD for thedevelopment of this infrastructure has been shown tolead to significantly increased performance of acutecare and secondary prevention measures.14,15 Hospitalparticipation and measures of system change includingclinical champion identification, multidisciplinaryteam creation, baseline and follow-up data collection,and the use of preprinted orders and protocols weretracked. GWTG-CAD hospital recognition based onthese process measures, as well as adherence to theGWTG-CAD measures, were also tracked as criteria forincentive payments. Thirteen hospitals that providedcare for HMSA patients were eligible for the incentiveprogram.


In February 2002, The AHA convened a stakeholdermeeting for GWTG-CAD, which including key Hawaiiorganizations and opinion leaders. The HMSA was astakeholder collaborating with the AHA to provideencouragement and incentives to hospitals for meaningfulparticipation in the program. These activitiesincluded cosponsorship of meetings, hospital recruitment,and reimbursement to participating hospitals forhalf of the yearly $900 fee for use of the PatientManagement Tool.

The financial incentive program was announced atthe first hospital workshop, reviewed in subsequentworkshops, and communicated directly to hospital chiefexecutive officers and chief financial officers in othermeetings and by written correspondence. Scoring forthe initial year made 140 points of the 1670 totalpotential points in the Hospital Quality and ServiceRecognition Program available to hospitals for GWTGCAD;60 of the 140potential points wereawarded. In somecases hospitals metthe point criteria forincentives after thedeadline for theincentive program orfailed to provide documentationof theiractivities as required;these hospitals didnot receive incentivesfor these elements. Amaximum of 10 pointswas available to eachhospital. Points earnedand financial incentivespaid to each hospitalare summarizedin Table 2.

These GWTG-CADpoints resulted in$354 883 awarded.This modest amountof dollars assigned toparticipation correlatedwith a high level ofparticipation totaling85% of Hawaii's eligible hospitals. Interviews withhospital administrators indicatedthat the incentives were used tosupport in the hospital quality improvementstaff salaries and travelcosts for hospital staff to attendGWTG-CAD workshops and relatedmeetings.

In workshops and conferencecalls, hospitals shared solutionsto program implementation barriers,leading to substantialchanges in the systems ofcare.They continue to collectpatient data and use the decisionsupport, communication tools,and reminders that are embeddedin the Patient ManagementTool.12 Thus far more than 2000patients have been included inthis program in Hawaii.


In this study, we demonstratedthat by providing financialincentives, the Hawaii GWTGCADprogram was able to secure active institutionalparticipation in implementation of system changes tosupport more uniform adoption of cardiovascularguidelines.

Based on previously published outcome data2-4 andthe progress of other GWTG hospitals in improvingguideline adherence,14,15 a significant and measurableimprovement in secondary prevention of coronaryartery disease in Hawaii is anticipated. Factors that correlatewith improvement including multidisciplinaryteams, collaborative support, and the use of the PatientManagement Tool for data, reporting, and decision supportare now in place. The GWTG-CAD program hasbecome the standard to improve cardiovascular careand is now being used in all but 1 hospital in Hawaii.The full participation of more than 85% of hospitals ismuch higher than would be predicted by models of "diffusionof innovation" in healthcare.16,17 Typically suchprograms attract early adopters and the early majoritythat would account for somewhat less than half of thehospitals in a market. In fact, 30% to 50% penetration ofGWTG-CAD has been commonly seen in most markets.Involvement of more than 85% would suggest significantengagement of the late majority as well. This findingsuggests that the presence of financial incentives tied tothe steps of participation may play an important role inspeeding the adoption of innovative programs such asGWTG-CAD.

This report documents the first, important steps toreach the goal of improved patient outcomes. Webelieve that financial incentives geared toward an establishedand successful process to improve care is a noveland important approach as the healthcare systembegins to explore the alignment of financial incentives,generally referred to as "pay for performance." Perhapsthis effort to help hospitals build the critical infrastructurein a larger proportion of hospitals in Hawaii than iscommonly seen could play a role in accelerating thetransformational change called for by the Institute ofMedicine.18

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.


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