Financial Incentives For Physicians Research Articles

The impact of the diabetes management incentive on diabetes-related services: evidence from Ontario, Canada

Financial incentives have been introduced in several countries to improve diabetes management. In Ontario, the most populous province in Canada, a Diabetes Management Incentive (DMI) was introduced to family physicians practicing in patient enrollment models in 2006. This paper examines the impact of the DMI on diabetes-related services provided to individuals with diabetes in Ontario. Longitudinal health administrative data were obtained for adults diagnosed with diabetes and their family physicians. The study population consisted of two groups: DMI group (patients enrolled with a family physician exposed to DMI for 3 years), and comparison group (patients affiliated with a family physician ineligible for DMI throughout the study period). Diabetes-related services was measured using the Diabetic Management Assessment (DMA) billing code claimed by patient's physician. The impact of DMI on diabetes-related services was assessed using difference-in-differences regression models. After adjusting for patient- and physician-level characteristics, patient fixed-effects and patient-specific time trend, we found that DMI increased the probability of having at least one DMA fee code claimed by patient's physician by 9.3% points, and the probability of having at least three DMA fee codes claimed by 2.1% points. Subgroup analyses revealed the impact of DMI was slightly larger in males compared to females. We found that Ontario's DMI was effective in increasing the diabetes-related services provided to patients diagnosed with diabetes in Ontario. Financial incentives for physicians help improve the provision of targeted diabetes-related services.

Cost-effectiveness of Financial Incentives for Patients and Physicians to Manage Low-Density Lipoprotein Cholesterol Levels

Financial incentives shared between physicians and patients were shown to significantly reduce low-density lipoprotein cholesterol (LDL-C) levels in a randomized clinical trial, but it is not known whether these health benefits are worth the added incentive and utilization costs required to achieve them. To evaluate the long-term cost-effectiveness of financial incentives on LDL-C level control. In this economic evaluation, a previously validated microsimulation computer model was parameterized using individual-level data from the randomized clinical trial on financial incentives, National Health and Nutrition Examination Surveys for model population inputs, and other published sources. The study was conducted from April 15, 2016, to March 29, 2018. The following interventions were used: (1) usual care, (2) trial control strategy (increased cholesterol level monitoring and use of electronic pill bottles), (3) financial incentives for physicians, (4) financial incentives for patients, and (5) incentives shared between physicians and patients. Discounted costs (2017 US dollars), lifetime cardiovascular disease risk, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs). The model population (n = 1 000 000 [30.7% women]) had similar mean (SD) age (61.5 [11.9] years) and LDL-C level (153.9 mg/dL) as the observed trial population (n = 1503 [42.7% women]; age, 62.0 [8.7] years; and LDL-C level, 160.6 mg/dL). Using base-case assumptions (including a 10-year waning period of LDL-C level reductions), the usual-care strategy was dominated (higher costs and lower QALYs) by all other strategies. Strategies for physician- or patient-only incentives were dominated by the shared-incentives strategy, which had an ICER of $60 000/QALY compared with the trial control strategy. In a sensitivity analysis regarding the duration of LDL-C level reductions, the shared-incentives strategy remained cost-effective (ICERs <$100 000/QALY and <$150 000/QALY) for scenarios with LDL-C level reductions lasting, with linear waning, at least 7 and 5 years, respectively. In the 1-way sensitivity analysis for the time horizon of the analysis, the ICER of the shared-incentives strategy exceeded $100 000/QALY at 11 years and $150 000/QALY at 8 years. In probabilistic sensitivity analysis, the shared-incentives intervention was cost-effective in 69% to 77% of iterations using cost-effectiveness thresholds of $100 000 to $150 000/QALY. Cost-effectiveness results were also sensitive to the duration of intervention costs. This study suggests that the financial incentives shared between patients and physicians for LDL-C level control meet conventional standards of cost-effectiveness, but these results appeared to be sensitive to assumptions about the durations of LDL-C level reductions and years of intervention costs included, as well as to the choice of time horizon.

Interoperability In Radiography Data: The Impossible Dream

Background: Technology in healthcare is changing at a very rapid pace. To ensure that technology is used efficiently to combat rising healthcare costs and new federal policies and laws, all technology must be able to communicate with each other. Therefore, interoperability must be obtained. Radiography is no exception considering all the different types of equipment manufactured routinely used today. Some barriers need to be overcome to achieve interoperability within radiography departments. Purpose: To review the literature on the interoperability of healthcare data to determine the barriers that Radiography departments would have to overcome to improve interoperability of their healthcare data. Methods: The methodology of this literature review follows the fundamental principles of a systematic search, conducted in separate stages, but is not a comprehensive systematic review, which was not reasonable due to resource constraints. The stages of the literature search included defining the search strategy, identifying the inclusion criteria, assessing the relevance and validity of the studies retrieved, and data extraction and synthesis. Results: There were attempts to ensure interoperability, such as the use of the Nationwide Health Information Network (NwHIN), but roadblocks such as financial incentives for physicians and costs of implantation have hindered the adoption of the NwHIN. Other barriers that limit interoperability exist. These obstacles included inconsistency of the Digital Imaging and Communication in Medicine (DICOM) standard for medical imaging departments and a complete lack of norms for certain data points such as the exposure index between different vendors. Discussion: Multiple viable options for the improvement of interoperability are prevalent in radiography departments. One such option is cloud computing, which uses multiple various types of hardware and software as resources to help interoperability of healthcare data. Agent-based technologies, which can be used to distribute management of different standards, can also be utilized to communicate between standards. The largest need to ensure interoperability is standards that are well defined and stringent with an infrastructure to map different terminologies across different standards. Conclusion: Various technological advances can be used to improve interoperability such as agent-based technology and cloud computing. However, until a standardization of terms within the DICOM protocol and a standard across vendors, and all data points standardized, it will be impossible to obtain true interoperability.

Disparate British Breast Reconstruction Utilization: Is Universal Coverage Sufficient to Ensure Expanded Care?

Summary:Our intent is to improve the understanding of the ability of healthcare providers to deliver high-quality care as we approach an era of universal coverage. We adopted 2 unique vantage points in this article: (1) the mandated coverage for immediate breast reconstruction (IBR) surgery as a microcosmic surrogate for universal coverage overall and (2) we then scrutinized the respective IBR utilization rates in a contemporaneous system of 2 healthcare delivery models in the United Kingdom, that is, the public National Health Service trust versus private-sector hospitals. A literature review was performed for IBR rates across public trust and private-sector hospitals in the United Kingdom. The IBR rate among public trust hospitals was 17% compared with 43% in the private sector. In the trust hospital setting, the enactment of 2 government mandates, intended to increase the access to cancer care, seemed to fall short in maximizing the ability of surgical practitioners to deliver quality care to patients. Among women who did not receive IBR, 65% felt that they had received the sufficient amount of information to appropriately inform their decision. In addition, only 46% of this same cohort reported a consultation with a reconstructive surgeon preoperatively. Private-sector hospitals delivered better IBR care because of the likely presence of infrastructure and financial incentives for physicians. These results serve as a call for a better alignment between policy initiatives designed to expand care access and the perogatives of physicians to ensure an optimized delivery of the expanded care such policy mandates.

Ensuring access to health care—Germany reforms supply structures to tackle inequalities

Germany's ruling coalition has recently introduced a new bill to Parliament, the Care Structures Act (CSA), which aims to improve outpatient care supply structures, decentralize decision-making, facilitate cross-sectoral treatment, and strengthen innovation in the nation's health care sector. These objectives are to be achieved through a variety of measures, including changes in financial incentives for physicians, the transfer of decision-making to the regional level, and the creation of a new sector for highly specialized care. The opposition parties in Parliament and most health care stakeholders agree on the objectives of the reform package, but their evaluation of the bill is mixed. Physicians' representative organizations generally deem the law to be headed in the right direction, while the opposition parties, sickness funds, patients' rights groups and a majority of German federal states (Bundesländer) feel it does not adequately address the issues of supply inequity and sectoral division. This skepticism seems well founded. The reforms aimed at attracting physicians to high-need regions have significant shortcomings, and the measures to overcome sectoral barriers between the outpatient care and hospital sectors remain weak. Furthermore, the new procedure for including innovative treatment methods in the SHI benefits catalogue falls short of internationally recognized standards.

Policy Update: Federal Incentives for the Adoption of Electronic Health Records.

The American Recovery and Reinvestment Act of 2009 provides financial incentives for physicians and hospitals to adopt electronic health records. Practices can take initial steps outlined here to receive bonus payments and avoid penalties.

The Elusive Quest for Quality and Cost Savings in the Medicare Program

MEDICARE IS A DOMINANT FORCE IN THE HEALTH care system of the United States. When it was launched as a national social insurance program for elderly and disabled Americans in 1965, Medicare was grafted onto the existing health care delivery system. Over the past 40 years, most physicians and hospitals have continued to receive regulated payments from Medicare with no limits on the volume of services provided and minimal oversight or coordination of care. In 2009, Medicare expenditures will exceed $400 billion, representing 13% of the federal budget and about one-fifth of all US expenditures on health care. This status quo, however, is not sustainable for Medicare. Last year, the Medicare trustees projected that the Hospital Insurance Trust Fund will be exhausted in 2019 without new measures to increase payroll taxes or contain the growth of expenditures. In response to similar concerns during the past decade, policymakers have started to implement and evaluate numerous new approaches to contain costs while maintaining or improving the quality of care in Medicare. These demonstration projects have tried to modify how care is coordinated or instituted new financial incentives for physicians and hospitals. A study reported by Peikes and colleagues in this issue of JAMA presents one of the most comprehensive evaluations of a Medicare demonstration project to date. In 2002, 15 programs were independently funded by the Centers for Medicare & Medicaid Services (CMS) to participate in the Medicare Coordinated Care Demonstration. The goals of the project were to determine whether enhanced care coordination could improve the quality of care or reduce Medicare expenditures for participating beneficiaries with serious chronic health conditions. With voluntary enrollment of more than 18 000 participants from all US regions, these 15 programs implemented a varied set of approaches to improve care coordination. Common features of the programs included the use of nurses trained as care coordinators to interact on a regular basis with patients who had serious chronic health conditions. These nurses provided patients with health education and sent written reports to their physicians. Participants were substantially sicker than Medicare beneficiaries in general, with much higher rates of cardiovascular disease, diabetes, and chronic lung disease, and correspondingly greater monthly Medicare expenditures before enrollment ($1535 vs $551, respectively). The CMS paid each program a negotiated monthly fee that averaged $235 per participant to provide outreach, health education, and support to these chronically ill patients—and in some cases to their physicians. An independent evaluation of these programs was funded by CMS to assess their effects on quality of care, hospitalizations, and Medicare expenditures in a consistent and rigorous manner. The program evaluation reported in this issue of JAMA has several strengths that merit highlighting. First, participants in each program were randomly assigned to interact with a care coordinator or to receive their usual care, ensuring that observable and unobservable characteristics were well balanced between intervention and control groups within each program. Second, complete Medicare claims data and nearly complete patient survey data were available to assess hospitalizations, expenditures, participants’ functional status, and an array of technical and patientcentered measures of quality of care. Third, 12 of the 15 programs had sufficient numbers of enrollees to detect a 20% change in rates of hospitalization and in Medicare expenditures during a 4-year period with reasonable statistical power. The financial and clinical results of this careful evaluation were sobering. Only 2 of the 12 largest programs had a statistically significant effect on the annual number of hospital admissions. A hospital-sponsored program in Iowa (Mercy Medical Center) significantly reduced hospitalizations by 17%, with a nonsignificant 9% reduction in Medicare expenditures. In contrast, a retirement center program in Maryland (Charlestown) significantly increased both hospitalizations and expenditures by 19%. When program fees were incorporated in the analysis, total expenditures were 8% to 41% higher (P .10) in the intervention groups

Financial incentives for physicians lead to improved patient care,

Financial incentives for physicians lead to improved patient care,

Putting Smart Money to Work for Quality Improvement

To investigate the effects of paying physicians for performance on quality measures of diabetes care when combined with other care management tools. In 2001, a managed care organization in upstate New York designed and implemented a pilot program to financially reward doctors for the quality of care delivered to diabetic patients. In addition to paying a performance bonus, physicians were also supplied with a diabetic registry and met in groups to discuss progress in meeting goals for diabetic care. Primary data on diabetes care at the patient level were collected from each physician during the 8-month period, April 2001-January 2002. Physicians were scored on individual process and outcome measures of diabetes care on three separate occasions; these individual scores were combined into a composite score on which the financial reward was allocated. The study design is pre/post for the patients whose physicians participated in the performance pay program. The control group is a large sample of the health plan's diabetic members. Data on patient outcomes were self-reported by physicians participating in the study. These data were audited with spot checks of medical charts. Data for the control group were collected as part of the health plan's annual HEDIS data collection. Physicians and patients achieved significant improvement on five out of six process measures, and on two out of three outcome measures (HbA1c control and LDL control). Thirteen out of 21 physicians improved their average composite score enough to earn some level of financial reward. Of the eight physicians not receiving any of the three levels of reward, six improved their composite scores. Financial incentives for physicians, bundled with other care management tools, led to improvement on objectively measured quality of care for diabetic patients. Self-selection by physicians into the pay pilot and the small sample size of participating physicians limit the generalizability of the results.

Influenza vaccination in Europe: an inventory of strategies to reach target populations and optimise vaccination uptake

A study was undertaken to assess influenza vaccine uptake in risk groups and to get insight into vaccination practices in European countries. Questionnaires were completed by national influenza experts from 26 countries. Only 14 were able to provide uptake rates for the elderly. For the other risk groups, even fewer could provide data. Vaccines are usually administrated by GPs. Financial incentives for physicians and patients might work as a strategy to increase uptake rates, but due to the small amount of data, it was not possible to carry out thorough multivariate analyses. The development of a uniform influenza vaccination monitoring method was recommended to allow for comparison of uptake data in Europe.

Financial Incentives for Physicians in Managed Care.

A hotly debated ethical issue in managed care is the use of financial incentives -- including bonuses and withholds from physicians' salaries -- to

Financial incentives for physicians: the Quebec experience.

This paper presents an empirical investigation of physician labour supply, based on a two-stage budgeting model, drawing on an analogy with consumer theory. Physicians' trade-offs between income and leisure constitute the first stage of the decision-making process. In turn, choices are made in the second stage concerning the choice of particular activities (hospital versus office care, for example) or procedures (ordinary versus complete medical examinations), given the total medical care activity chosen in the first stage. The objective of the study is to identify physicians' responses to exogenous shocks in the remuneration system. The focus of analysis is shifted away from the identification of Supply-Induced Demand (SID) to a more pragmatic analysis of some of the determinants of physicians' choices. The study uses monthly activity data on a panel of 677 Québec GPs between 1977 and 1983. Quantity adjustments and drifts to more complex (and therefore better paid) procedures are evidenced, mainly in response to a fifteen month tariff-freeze. Physicians' ability to control their own work loads is also documented, both in terms of timing and level of complexity, and expenditure caps (in the form of an individual ceiling on GPs' quarterly gross income) are found to be effective at curbing high activity rates.

Financial incentives for physicians in HMOs. Is there a conflict of interest?

Do financial incentives used by health maintenance organizations (HMOs) to restrain the use of health care resources represent a conflict of interest between physicians' concern about their income and their concern about patients? To explore the contractual obligations of primary care physicians in HMOs, I mailed a survey to all 595 HMOs known to be in operation as of June 1986. In all, 302 of 595 HMOs (51 percent) responded. Sixty-seven percent of plans with capitation-based arrangements and 82 percent of plans with fee-for-service arrangements withhold a percentage of their physicians' income against potential deficits, but only 21 percent of plans with salaried physicians do so. Thirty percent of HMOs have other penalties in addition to this withholding. Eighteen percent of HMOs base the return of the withheld amount on the experience of individual physicians rather than on the collective experience of a group of physicians. For-profit HMOs are less likely to use salary-based payment, more likely to withhold a percentage of income, and more likely to base the return of this withheld amount on the experience of individual physicians. Most HMOs have mechanisms for sharing surpluses with participating physicians. I conclude that contractual arrangements in HMOs vary widely. Certain financial incentives, especially when used in combination, suggest conflicts of interest that may influence physicians' behavior and adversely affect the quality of care.