Abstract
Specialist physicians are key members of chronic care management teams; to date, however, little is known about the association between specialist payment models and outcomes for patients with chronic diseases. To examine the association of payment model with visit frequency, quality of care, and costs for patients with chronic diseases seen by specialists. A retrospective cohort study using propensity-score matching in patients seen by a specialist physician was conducted between April 1, 2011, and September 31, 2014. The study was completed on March 31, 2015, and data analysis was conducted from June 2017 to February 2018 and finalized in August 2019. In a population-based design, 109 839 adults with diabetes or chronic kidney disease newly referred to specialists were included. Because patients seen by independent salary-based and fee-for-service (FFS) specialists were significantly different in observed baseline characteristics, patients were matched 1:1 on demographic, illness, and physician characteristics. Specialist physician payment model (salary-based or FFS). Follow-up outpatient visits, guideline-recommended care delivery, adverse events, and costs. A total of 90 605 patients received care from FFS physicians and 19 234 received care from salary-based physicians. Before matching, the patients seen by salary-based physicians had more advanced chronic kidney disease (2630 of 14 414 [18.2%] vs 6627 of 54 489 [12.2%]), and a higher proportion had 5 or more comorbidities (5989 of 19 234 [31.3%] vs 23 326 of 90 605 [25.7%]). Propensity-score matching resulted in a cohort of 31 898 patients (15 949 FFS, 15 949 salary-based) seeing 489 specialists. In the matched cohort, patients were similar (mean [SD] age, 61.3 [18.2] years; 17 632 women [55.3%]; 29 251 residing in urban settings [91.7%]). Patients seen by salary-based specialists had a higher follow-up visit rate compared with those seen by FFS specialists (1.74 visits; 95% CI, 1.58-1.92 visits vs 1.54 visits; 95% CI, 1.41-1.68 visits), but the difference was not significant (rate ratio, 1.13; 95% CI, 0.99-1.28; P = .06). There was no statistical difference in guideline-recommended care delivery, hospital or emergency department visits for ambulatory care-sensitive conditions, or costs between patients seeing FFS and salary-based specialists. The median association of physician clustering with health care use and quality outcomes was consistently greater than the association with the physician payment, suggesting variation between physicians (eg, median rate ratio for follow-up outpatient visit rate was 1.74, which is greater than the rate ratio of 1.13). Specialist physician payment does not appear to be associated with variation in visits, quality, and costs for outpatients with chronic diseases; however, there is variation in outcomes between physicians. This finding suggests the need to consider other strategies to reduce physician variation to improve the value of care and outcomes for people with chronic diseases.
Highlights
Noncommunicable chronic diseases pose a major challenge for health systems worldwide owing to rising prevalence and costs.[1]
Specialist physician payment does not appear to be associated with variation in visits, quality, and costs for outpatients with chronic diseases; there is variation in outcomes between physicians
We excluded 2882 patients undergoing dialysis, 670 with kidney or islet cell transplants, 10 378 who had preoperative index visits, and 2103 whose physicians switched payment models during the study, resulting in a cohort of 109 839 adults with diabetes or nondialysis chronic kidney disease (CKD) newly referred to specialist physicians
Summary
Noncommunicable chronic diseases pose a major challenge for health systems worldwide owing to rising prevalence and costs.[1] Chronic disease management models have focused on the role of primary care[2]; specialists are key members of the chronic care team providing additional support and care to patients with more complex needs.[3] Outpatient care for chronic conditions is frequently suboptimal. There is a robust literature on the association between payment mechanisms and physician behavior, but most of the empirical work addresses primary care payment and little is known about how specialists respond to payment models in general or, when caring for patients with chronic diseases. Few quasi-experimental studies of specialist payment have examined quality outcomes, and limited data exist on the outcomes associated with costs.[15]
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