Incentives For Physicians Research Articles

Assessment of rural emergency department physician staff, hiring practices and needs.

Rural communities suffer from an unequal access to health-care resources. The purpose of this study was to characterise Emergency Departments (EDs) in the Champlain Local Health Integration Network (LHIN) and determine their barriers to recruitment and retention of emergency physicians. A survey was sent to the 17 ED chiefs in the Champlain LHIN area by E-mail through May to December 2019. Results were analyzed for common themes and trends. Seven of the 17 hospitals responded to the survey. The average number of physicians staffing the ED was 16, with the majority being Canadian College of Family Physicians certified without additional emergency training. Common described barriers to recruitment include lack of incentives for physicians to work in rural communities, lack of available resources at rural centres, such as specialists and poor flexibility in terms of shift coverage. Barriers to retention included limited incentives to remain in rural communities. This study analyzed the demographics and barriers to recruitment and retention in rural EDs. These results can be used to help build strategies that encourage physicians to practise in rural EDs.

For-Profit Hospitals Have Thrived Because of Generous Public Reimbursement Schemes, Not Greater Efficiency: A Multi-Country Case Study.

For-profit hospitals’ market share has increased in many nations over recent decades. Previous studies suggest that their growth is not attributable to superior performance on access, quality of care, or efficiency. We analyzed other factors that we hypothesized may contribute to the increasing role of for-profit hospitals. We studied the historical development of the for-profit hospital sector across 4 nations with contrasting trends in for-profit hospital market share: the United States, the United Kingdom, Germany, and the Netherlands. We focused on 3 factors that we believed might help explain why the role of for-profits grew in some nations but not in others: (1) the treatment of for-profits by public reimbursement plans, (2) physicians’ financial interests, and (3) the effect of the political environment. We conclude that access to subsidies and reimbursement under favorable terms from public health care payors is an important factor in the rise of for-profit hospitals. Arrangements that aligned financial incentives of physicians with the interests of for-profit hospitals were important in stimulating for-profit growth in an earlier era, but they play little role at present. Remarkably, the environment for for-profit ownership seems to have been largely immune to political shifts.

The Impact of Preoperative Depression on Patient Satisfaction With Spine Surgeons in the Outpatient Setting.

Retrospective review. The aim of this study was to examine the association between preoperative depression and patient satisfaction in the outpatient spine clinic after lumbar surgery. The Clinician and Group Assessment of Healthcare Providers and Systems (CG-CAHPS) survey is used to measure patient experience in the outpatient setting. CG-CAHPS scores may be used by health systems in physician incentive programs and quality improvement initiatives or by prospective patients when selecting spine surgeons. Although preoperative depression has been shown to predict poor patient-reported outcomes and less satisfaction with the inpatient experience following lumbar surgery, its impact on patient experience with spine surgeons in the outpatient setting remains unclear. Patients who underwent lumbar surgery and completed the CG-CAHPS survey at postoperative follow-up with their spine surgeon between 2009 and 2017 were included. Data were collected on patient demographics, Patient Health Questionnaire 9 (PHQ-9) scores, and Patient-Reported Outcome Measurement Information System Global Health Physical Health (PROMIS-GPH) subscores. Patients with preoperative PHQ-9 scores ≥10 (moderate-to-severe depression) were included in the depressed cohort. The association between preoperative depression and top-box satisfaction ratings on several dimensions of the CG-CAHPS survey was examined. Of the 419 patients included in this study, 72 met criteria for preoperative depression. Depressed patients were less likely to provide top-box satisfaction ratings on CG-CAHPS metrics pertaining to physician communication and overall provider rating (OPR). Even after controlling for patient-level covariates, our multivariate analysis revealed that depressed patients had lower odds of reporting top-box OPR (odds ratio [OR]: 0.19, 95% confidence interval [CI]: 0.06-0.63, P = 0.007), feeling that their spine surgeon provided understandable explanations (OR: 0.32, 95% CI: 0.11-0.91, P = 0.032), and feeling that their spine surgeon provided understandable responses to their questions or concerns (OR: 0.19, 95% CI: 0.06-0.63, P = 0.007). Preoperative depression is independently associated with lower OPR and satisfaction with spine surgeon communication in the outpatient setting after lumbar surgery.Level of Evidence: 3.

The classic “Carrot-and-stick approach”: Addressing underutilization of ICD-10 increased data granularity

The classic “Carrot-and-stick approach”: Addressing underutilization of ICD-10 increased data granularity

Delivery of essential surgery by family physicians.

Primary health care provides the framework for delivering the socially-informed, comprehensive and patient-centred care underlying robust health-care systems and is, therefore, central to achieving universal health coverage. Family physicians are best placed to embody primary health care’s dual focus on community and population health because they are often employed in rural or district hospitals with limited human resources, particularly a lack of specialists. Here we want to illustrate how additional training for family physicians, the key clinicians in primary care, can play a critical role in reducing disparities in access to surgical, obstetric and anaesthesia care in low- and middle-income countries and in rural or remote settings. Examples are given of how training programmes can be developed in low-resource settings to equip family physicians with life-saving surgical skills and of how family physicians in high-income countries can be trained in the surgical skills essential for working overseas in low-income settings. Policy-makers should promote surgical practice among family physicians by supporting family medicine programmes that include additional surgical skills training and by expanding opportunities and incentives for family physicians to serve in rural areas. Moreover, national surgical plans should include a primary health care strategy for surgical care and, globally, family physicians should be considered in discussions of surgical care. Finally, surgeons, anaesthesiologists, obstetricians and family physicians should be encouraged to collaborate in ensuring that all patients, regardless of place of residence, receive safe and timely surgical care.

Where Are We in the Transition to Value‐Based Payments?: Findings from a Study on Health System Physician Compensation Arrangements and Financial Incentives for Performance

Policymakers continue to set aggressive targets for alternative payment model engagement, aiming to spur a transition from volume‐ to value‐oriented payment to drive performance improvements. However, the extent to which payments to providers have transitioned to paying for value is unclear. Given their greater ability to enter into payment arrangements with financial risk, health systems may be particularly well‐positioned to reflect value‐orientation in their physician compensation and incentives. In this study, we sought to characterize frontline physician compensation and financial incentives for health system affiliated physician organizations (POs).Between 2017 and 2019, we fielded surveys and conducted semi‐structured interviews with leaders of POs affiliated with health systems. The interviews elicited the structure and features of compensation arrangements for primary care physicians (PCPs) and specialists and the POs’ revenues and incentives from payers. The survey addressed the structure of financial incentives and the top three actions physicians could take to increase their compensation. We assessed the frequency of compensation and financial incentive components and the association between POs’ fee‐for‐service revenue and their physicians’ productivity‐based compensation.A purposive sample of 28 POs in 24 not‐for‐profit health systems in California, Minnesota, Wisconsin, and Washington, of which all provided PCP compensation information and all but 2 provided specialist compensation information.Among included POs, financial performance incentives were used by 25 (89.3%) for PCPs, averaging 4.0% of total compensation (range 0.05% to 13.72%) and 16 (61.5%) for specialists, averaging 3.1% of compensation (range 0.5% to 13.0%). Productivity was the most common base compensation component for both PCPs (24 POs, 85.7%) and specialists (25 POs, 96.2%). Capitation and salary were also commonly used for both PCPs (8 POs, 28.6% and 6 POs, 21.4%, respectively) and specialists (3 POs, 11.5% and 6 POs, 23.1%, respectively). When included as a component of PCP compensation productivity averaged 62.4% of compensation, salary 62.5%, and capitation 46.1%. Increasing productivity was cited as the top action physicians could take to increase their compensation by 19 POs (67.9%) for PCPs and 19 POs (73.1%) for specialists. Improving clinical quality was next most commonly cited action to increase compensation for both PCPs and specialists. The correlation between PO’s percent fee‐for‐service revenue and their physicians’ percent productivity‐based compensation was moderately positive (r = .52) for PCPs and weakly positively for specialists (r = .40).Among health system POs, productivity is the most prominent component of PCP and specialist compensation and the most commonly noted means for physicians to increase their income. Financial performance incentives were commonly used but comprised a very small portion of total compensation. POs’ fee‐for‐service revenue percentage was more strongly positively correlated with the percentage compensation for productivity for PCPs than for specialists.Despite emphasis on transitioning from volume‐ to value‐based payment, productivity remains the principal component of physician compensation in health system affiliated POs that may have greater capacity and motivation to develop alternate compensation and incentive schemes. The ongoing primacy of productivity incentives for frontline physicians is likely to blunt the impact of value‐oriented payment and delivery system reforms.Agency for Healthcare Research and Quality.

Understanding antibiotic overprescribing in China: A conversation analysis approach.

Antibiotic resistance and its associated overprescription constitute one of the biggest global public health crises nowadays. Although widely recognized in high-income countries, the problem has not received enough attention and is not understood in the context of middle- and low-income countries. In this study, using a conversation analysis (CA) approach, I examine the antibiotic treatment decisions in naturally occurring medical encounters in China. The results show that, contrary to the prevailing theory of the physician incentive structure as the sole driver, antibiotic overprescription can be interactively achieved and significantly influenced by patients and caregivers in medical encounters. This suggests that management of patient caregivers' expectations for antibiotic treatment and the training of physicians' interactional skills in responding to patient/caregiver pressure in medical interactions have great potential for curbing the problem of antibiotic overprescription in China.

Do physician incentives increase patient medication adherence?

To test the effectiveness of physician incentives for increasing patient medication adherence in three drug classes: diabetes medication, antihypertensives, and statins. Pharmacy and medical claims from a large Medicare Advantage Prescription Drug Plan from January 2011 to December 2012. We conducted a randomized experiment (911 primary care practices and 8,935 nonadherent patients) to test the effect of paying physicians for increasing patient medication adherence in three drug classes: diabetes medication, antihypertensives, and statins. We measured patients' medication adherence for 18 (6) months before (after) the intervention. We obtained data directly from the health insurer. We found no evidence that physician incentives increased adherence in any drug class. Our results rule out increases in the proportion of days covered by medication larger than 4.2 percentage points. Physician incentives of $50 per patient per drug class are not effective for increasing patient medication adherence among the drug classes and primary care practices studied. Such incentives may be more likely to improve measures under physicians' direct control rather than those that predominantly reflect patient behaviors. Additional research is warranted to disentangle whether physician effort is not responsive to these types of incentives, or medication adherence is not responsive to physician effort. Our results suggest that significant changes in the incentive amount or program design may be necessary to produce responses from physicians or patients.

Commentary on "Do physician incentives increase patient medication adherence?"

None declared.

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.

Implementation of a Physician Incentive Program for 18-Month Developmental Screening in Ontario, Canada

To evaluate factors associated with uptake of a financial incentive for developmental screening at an enhanced 18-month well-child visit (EWCV) in Ontario, Canada. Population-based cohort study using linked administrative data of children (17-24months of age) eligible for EWCV between 2009 and 2017. Logistic regression modeled associations of EWCV receipt by provider and patient characteristics. Of 910 976 eligible children, 54.2% received EWCV (annually, 39.2%-61.2%). The odds of assessment were lower for socially vulnerable children, namely, those from the lowest vs highest neighborhood income quintile (aOR, 0.84; 95% CI, 0.83-0.85), those born to refugee vs nonimmigrant mothers (aOR, 0.90; 95% CI, 0.88-0.93), and to teenaged mothers (aOR, 0.70; 95% CI, 0.69-0.71)). Children were more likely to have had developmental screening if cared for by a pediatrician vs family physician (aOR, 1.28; 95% CI, 1.13-1.44), recently trained physician (aOR, 1.38; 95% CI, 1.29-1.48 for ≤5years in practice vs ≥21years) and less likely if the physician was male (aOR, 0.64; 95% CI, 0.61-0.66). For physicians eligible for a pay-for-performance immunization bonus, there was a positive association with screening. In the context of a universal healthcare system and a specific financial incentive, uptake of the developmental assessment increased over time but remains moderate. The implementation of similar interventions or incentives needs to account for physician factors and focus on socially vulnerable children to be effective.

Biosimilars in Belgium: a proposal for a more competitive market

ABSTRACT More than ten years after the first biosimilars were authorized for use in the European Union, Belgium still experiences limited competition from biosimilars, as exemplified by low market shares. Achieving high biosimilar market shares is not necessarily a goal in itself, as cost savings are also realized by mandatory price reductions on originator medicines in Belgium. However, we believe that biosimilars play a role in ensuring the long-term sustainability of the off-patent biologicals market. It is therefore crucial to list what has been done and what is needed to support the Belgian government in establishing a policy framework for a competitive off-patent biologicals market. We provide a comprehensive overview of the Belgian biosimilar market, including existing hurdles for biosimilar use in Belgium. Based on these hurdles and supplemented with learnings from other European countries, we propose practical recommendations that can be implemented to overcome them. Several Belgian stakeholders had the opportunity to comment on these recommendations. Specifically, we suggest to evolve towards a long-term consistent, integrated policy framework via i) the creation of a proactive and transparent climate supporting a level playing field for both biosimilar and reference product, including public dissemination of how savings at the level of the Belgian healthcare system are used, ii) investment in educational activities, including raising awareness of societal responsibility, iii) enforcement of the practical implementation of public procurement law, and iv) the development of incentives for physicians, who are key stakeholders in the Belgian off-patent biologicals market.

The Business of Healthcare: The Role of Physician Integration in Bundled Payments

Under the prevailing fee-for-service payments (FFS), hospitals receive a fixed payment, while physicians receive separate fees for each treatment or procedure performed for a given diagnosis. Incentives of hospitals and physicians are therefore misaligned under FFS, leading to large inefficiencies. Bundled payments (BP), an alternative to FFS unifying payments to the hospital and physicians, are expected to encourage care coordination and reduce ever increasing healthcare costs. However, as hospitals differ in their relationships with physicians in influencing care (level of physician integration), the expected effects of bundling in hospital systems with varying level of physician integration remains unclear. To fill this gap, we formulate game-theoretic models to study (1) the impact of the level of integration between the hospital and physicians in the uptake of BP, (2) the consequences of bundling with respect to overall care quality and costs/savings across the spectrum of integration levels. We find that (1) hospitals with low to moderate levels of physician integration are more likely to bundle as compared with hospitals with high physician integration; (2) to engage physicians, hospitals need to gainshare savings with physicians, a mechanism that was not available in traditional FFS-based payment models; (3) when feasible, BP is expected to reduce care intensity, and this reduction in care intensity is expected to result in quality improvement and cost savings in hospital systems with low to moderate level of physician integration; (4) however, when bundling happens in hospital systems with relatively higher level of physician integration, BP may lead to underprovision of care and ultimately quality reduction, and (5) in an environment where hospitals are also held accountable for quality, the incentives for bundling will be higher for involved parties, yet quality vulnerabilities due to bundling can be exacerbated. Our findings have important managerial implications for policy-makers and payers such as CMS, and hospitals: (1) policy makers and payers should be aware of and account for potential negative effects of current BP design on a subset of hospital systems, including a possible quality reduction, and (2) in deciding whether to enroll in BP, hospitals should consider their level of physician integration and possible implications for quality. Based on our findings, we expect that a widespread use of BP may trigger further market concentration via hospital mergers or service-line closures.

Physician Incentives and Sex/Gender Differences in Depression Care: An Interrupted Time Series Analysis.

Introduction: Physician incentives have been shown to reduce socioeconomic disparities in health care. The impact on sex/gender inequalities, however, has rarely been investigated. Using population-based data, this study investigated sex/gender differences in depression care and the impact of physician incentives.Methods: Deidentified health data from physician claims, hospitals, vital statistics, prescription database, and insurance plan registries in British Columbia, Canada, were examined, retrospectively. Individuals with depression were identified and their use of mental health services was tracked for 12 months following initial diagnosis. The following indicators were assessed: (1) counseling/psychotherapy (CP), (2) minimally adequate counseling/psychotherapy (MACP), (3) antidepressant therapy (AT), and (4) minimally adequate antidepressant therapy (MAAT). Sex/gender differences in these indicators before (January 2005–December 2007) and after (January 2008–December 2012) the introduction of physician incentives were estimated using interrupted time series analysis.Results: Preintervention, the percentage of individuals with depression who received CP was higher among males (CP: 58.4%, MACP: 13.6%) than females (CP: 57.1%, MACP: 10.9%). In contrast, the percentage who received AT was higher among females (AT: 57.7%, MAAT: 47.4%) than males (AT: 53.6%, MAAT: 41.9%). These statistically significant sex/gender differences remain unchanged postintervention.Conclusions: Sex/gender differences in depression care persist despite the introduction of physician incentives.

Transplant physician and surgeon compensation: A sample framework accounting for nonbillable and value-based work.

Work relative value unit (wRVU)-based fee schedules are predominantly used by both the Centers for Medicare & Medicaid Services (CMS) and private payers to determine the payments for physicians' clinical productivity. However, under the Affordable Care Act, CMS is transitioning into a value-based payment structure that rewards patient-oriented outcomes and cost savings. Moreover, in the context of solid organ transplantation, physicians and surgeons conduct many activities that are neither billable nor accounted for in the wRVU models. New compensation models for transplant professionals must (1) justify payments for nonbillable work related to transplant activity/procedures; (2) capture the entire academic, clinical, and relationship-building work effort as part of RVU determination; and (3) move toward a value-based compensation scheme that aligns the incentives for physicians, surgeons, transplant center, payers, and patients. In this review, we provide an example of redesigning RVUs to address these challenges in compensating transplant physicians and surgeons. We define a customized RVU (cRVU) for activities that typically do not generate wRVUs and create an outcome value unit (OVU) measure that incorporates outcomes and cost savings into RVUs to include value-based compensation.

Intersectoral Cost of Treating Pulmonary Non-Tuberculosis Mycobacterial Disease (NTM-PD) in Germany-A Change of Perspective in Disease Management.

Background: In line with its increasing prevalence, pulmonary Mycobacterium avium complex (MAC) disease (MAC-PD) gives rise to substantial healthcare costs. However, there is only limited information on the costs of intersectoral reimbursement. Objectives: Inpatient and outpatient costs for diagnosing and treating pulmonary MAC-PD in Germany in accordance with standard international guidelines were calculated and their potential effects on MAC disease management in Germany were determined. Methods: Hospitalization costs were calculated by using the German diagnosis related group (G-DRG) browser, with and without inclusion of the diseases most often associated with M. avium. Separated by drug macrolide susceptibility and severity of MAC-PD, the direct medical costs of suitable therapies in the outpatient setting were determined by Monte-Carlo simulation, including all conceivable options. Results: According to our simulation, the weighted mean cost of outpatient treatment over 14 or 18 months, in either case followed by a post-treatment monitoring over 12 months, amounts to €8675.22 (95% confidence interval [CI] €8616.17 to €8734.27). Of that amount, the revenue for outpatient doctors´ services, dependent on treatment duration, is low, ranging between €894.79 (10.3%) and €979.42 (11.3%), accordingly. Mean drug costs for MAC-PD patients amount to €6130.25 [95% CI €6073.52 to €6186.98], i.e., more than two third (70.7%) of the total outpatient costs. In contrast, the non-surgical reimbursement for a hospital stay of up to 14 days is €3321.64. Hospital reimbursement does not increase in cases of complications (a higher number and/or challenging type of associated diseases), but it is fully paid even in cases that require as few as 2 days of hospitalization. Conclusion: The imbalance between well-rewarded hospital care and the low reimbursement for long-term treatment of MAC-PD outpatients may induce inappropriate disease management. In order to arrive at properly integrated care of MAC-PD patients in Germany, measures such as better incentives for physicians in the outpatient setting and a targeted use of resources in hospitals are required. Reimbursed, periodic case conferences between outpatient physicians and experts in hospitals as well as preventive short-term checks of MAC-PD patients in specialty clinics may promote cross-sector cooperation and improve overall treatment quality. Nationwide pilot studies are required to gain evidence on the effectiveness of the new approach.

Diagnostic-combined groups as a personalization tool of doctor’s financial stimulation level and predictor of treatment cost

Introduction: The mechanism of formation and use of clinical-statistical groups and diagnostic-combined groups (DSG) as a tool for determining the cost of physician work, personification of the level of financial stimulation of his quality work is proposed based on the example of ENT diseases of different degrees of complexity. Purpose: As a result of the comparative characterization of physicians' work indicators management of diseases of five degrees of complexity, proposition to recommend the mechanism of substantiation of the levels of financial renumeration of the doctor and the possible options for reimbursement of a certain amount of the total cost of treatment. Material and Methods: We performed retrospective analysis of case histories and outpatient charts of otorhinolaryngological patients of the regional hospital for 10 years. Taking into account certain features of the clinical course of the disease, indicators of the average working time of the doctor for the process of examination and treatment, we recommend clinical-statistical groups, divided into four which amounted to five DCG, ie diseases of five degrees of complexity. Also, a formula is proposed in which, on the basis of official data on the amount of salaries of doctors, the terms of their regulatory expenses, the so-called "increasing" coefficients, an attempt was made to determine the cost of physicians' work according to the degree of complexity of the disease and to identify possible sources of compensation to the patient from the amount of the total cost of treatment. Results and discussion: Appropriate calculations indicated the opportunity to justify certain amounts of financial incentives for physicians, depending on the number of patients treated with varying degrees of complexity. Possible official sources of financial compensation to the patient of a certain amount of the total cost of his treatment were also identified. Conclusions: Given the creation of computer programs that would greatly simplify the corresponding calculations of the tables presented in the article, the recommended algorithm for practical implementation of the clinical-statistical groups and DCG system would be methodologically suitable for use in other (therapy, surgery, etc.) profile services of healthcare establishment.

Evidence-Based Practice in the Global Setting: An International Survey of Hypofractionation

Multiple large clinical trials have established the equivalence or non-inferiority of hypofractionated radiotherapy compared to conventionally fractionated treatment. The objective of this study is to determine real-world variations in the adoption of hypofractionation across different geographic regions and practice settings for cancers of the breast, prostate, and cervix, and for bone metastases, and barriers and facilitators to such adoption. An anonymous, electronic survey was distributed from January to December 2018 in English, Spanish, and Mandarin to radiation oncologists through the ESTRO Global Impact of Radiotherapy in Oncology initiative. There were 2,259 respondents from Europe (56%), Asia Pacific (19%), Middle East (5%), 12% Latin America, (12%), North America (6%), and Africa (2%). This survey assessed preference for hypofractionation and specific fractionation regimens across 4 disease sites (breast, prostate, cervix, and bone metastases) in curative and palliative scenarios. Perceived barriers and facilitators to adoption were evaluated. In regression analyses, hypofractionation preference was defined as use of hypofractionation for >75% of patients within each disease site and in >50% of clinical scenarios overall. Hypofractionation preference was more common in node-negative than in node-positive breast cancer (83% vs 46%, respectively; p<0.001), in low- and intermediate- vs. high-risk prostate cancer or cases requiring pelvic irradiation (56% vs. 32%, respectively; p=0.00001); hypofractionation was more common in North America and Europe than other regions. In cervix cancer, hypofractionation was preferred in 30% of locally advanced cervical cancer cases in Africa, but in <10% of cases in other regions. For palliative symptom control, hypofractionation was preferred by 93%, 91%, and 84% of respondents for breast cancer, prostate cancer, and cervix cancer respectively, and in 95% for bone metastases (p<0.001) across geographic regions. Lack of long-term data, inferior local control, toxicity, and inadequate technology were the most commonly cited barriers. In adjusted analyses, hypofractionation preference was associated with age <55 (odds ratio [OR] = 1.46, 95% CI 1.23 to 1.88), practice in a high-income country (OR=2.72, 95% CI 2.12 to 3.49), in a university setting (OR=1.30, 95% CI 1.04 to 1.67), in a center with a catchment area with >1,000,000 population (OR=1.57, 95% CI 1. to 2.0), and with intensity modulated radiotherapy (OR=1.70, 95% CI 1.22 to 2.34). Significant variation was observed in preference for hypofractionation across indications and between geographic regions, with greater concordance in preference for palliative indications. Improving the cost-effectiveness of radiotherapy and the quality of care delivered requires greater international attention to continuing medical education and policy reform that aligns evidence-based practice with physician incentives.

THE ROLE OF REGIONAL PROGRAMS OF SOCIAL ECONOMIC INCENTIVES IN INVOLVEMENT OF MEDICAL PERSONNEL TO RURAL HEALTH CARE

The study established impacting of regional activities of social economic incentives of medical personnel on the process of employment in medical institutions of rural area. The analysis of Federal and regional legislation regulating process of incentives of physicians to employment in rural health care system was implemented. The study material was based on the results of implementation of activities of social economic incentives of medical personnel to join rural medical institutions applied in the territory of the Nizhny Novgorod region in 2006-2017. The comparative analysis was implemented concerning normative base of activities of social economic support of physicians including assessment of quality and scope of material preferences and also analysis of effect of types of material incentives on amount of input of specialists in rural health care. The comparative characteristics are presented concerning regional activities of supporting rural medical personnel with ready-made accommodation and vehicles and also assessment of federal activities related to granting rural physicians with single compensation payment of one million rubles. The implemented study demonstrated that problem of recruitment of medical personnel in general and in rural health care in particular is an extremely complicated task. The Federal and regional health authorities were engaged in development of alternatives of solution of this problem until now. It is established that a significant importance in decision making related to employment in rural medical institutions is attached to implementing programs of social economic support. It is derived that measures of social economic support related to granting ready-made accommodation within the framework of regional activities favored more active involvement and long-term assignment of medical personnel in rural area than granting with single compensation payment of one million rubles.

Effective Contract and Motivation: Can Reforms Improve the Work of Russian Doctors?

Since 2012 the reform of the salary system of workers in the budgetary sphere, called the introduction of an effective contract, has been implemented in Russia. The paper presents the results of a study of the reform impact on the labor motivation of physicians. Empirical data are obtained by conducting in-depth interviews with physicians and heads of state medical institutions in Moscow and one of the regions in the European part of the country in 2016. The study revealed multidirectional impact for physicians’ readiness to work more and better by effective contract. There are three groups of doctors. The first and largest group: physicians who feels a positive impact of motivation incentives for physicians’ motivation at work. The second group: physicians who are convinced that an effective contract does not affect their motivation. The third group: physicians who believe that effective contract has led to a weakening of physicians’ motivation. The article gives an explanation of the results of the study. Results of the study also clearly show that the changes in the physician’s remuneration system aimed exclusively on the growth of salary of doctors are necessary, but not sufficient. The impact of an effective contract on the achievement motivation (the desire to improve their professional capabilities and results) was different for experienced and young doctors. The most pronounced increase in the achievement motivation was observed for the majority of young doctors. A special part of the research paper is devoted to informal payments which influence physicians’ motivation. The research has shown that these payments may smooth motivational effect caused by the new rules of remuneration. This fact is typical for Moscow, while in the region, this effect is not clearly expressed.