Physician perception of reimbursement for outpatient procedures among managed care patients with diabetes mellitus.
ABSTRACT To examine the association between physicians' reimbursement perceptions and outpatient test performance among patients with diabetes mellitus.
Participants were physicians (n = 766) and their managed care patients with diabetes mellitus (n = 2758) enrolled in 6 plans in 2003. Procedures measured included electrocardiography, radiography or x-ray films, urine microalbumin levels, glycosylated hemoglobin levels, and Pap smears for women. Hierarchical logistic regression models were adjusted for health plan and physician-level clustering and for physician and patient covariates. To minimize confounding by unmeasured health plan variables, we adjusted for health plan as a fixed effect. Therefore, we estimated variation between physicians using only the variance within health plans.
Patients of physicians who reported reimbursement for electrocardiography were more likely to undergo electrocardiography than patients of physicians who did not perceive reimbursement (unadjusted mean difference, 4.9%; 95% confidence interval, 1.1%-8.9%; and adjusted mean difference, 3.9%; 95% confidence interval, 0.2%-7.8%). For the other tests examined, no significant differences in procedure performance were found between patients of physicians who perceived reimbursement and patients of physicians who did not perceive reimbursement.
Reimbursement perception was associated with electrocardiography but not with other commonly performed outpatient procedures. Future research should investigate how associations change with perceived amount of reimbursement and their interactions with other influences on test-ordering behavior such as perceived appropriateness.
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ABSTRACT: To examine associations between physician reimbursement incentives and diabetes care processes and explore potential confounding with physician organizational model. Primary data collected during 2000-2001 in 10 managed care plans. Multilevel logistic regressions were used to estimate associations between reimbursement incentives and process measures, including the receipt of dilated eye exams, foot exams, influenza immunizations, advice to take aspirin, and assessments of glycemic control, proteinuria, and lipid profile. Reimbursement measures included the proportions of compensation received from salary, capitation, fee-for-service (FFS), and performance-based payment; the performance-based payment criteria used; and interactions of these criteria with the strength of the performance-based payment incentive. Patient, provider group, and health plan surveys and medical record reviews were conducted for 6,194 patients with diabetes. Without controlling for physician organizational model, care processes were better when physician compensation was based primarily on direct salary rather than FFS reimbursement (four of seven processes were better, with relative risks ranging from 1.13 to 1.23) or capitation (six were better, with relative risks from 1.06 to 1.36); and when quality/satisfaction scores influenced physician compensation (three were better, with relative risks from 1.17 to 1.26). However, these associations were substantially confounded by organizational model. Physician reimbursement strategies are associated with diabetes care processes, although their independent contributions are difficult to assess, due to high correlation with physician organizational model. Regardless of causality, a group's use of quality/satisfaction scores to determine physician compensation may indicate delivery of high-quality diabetes care.Health Services Research 09/2006; 41(4 Pt 1):1221-41. DOI:10.1111/j.1475-6773.2006.00533.x · 2.49 Impact Factor
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ABSTRACT: Public reporting and pay for performance are intended to accelerate improvements in hospital care, yet little is known about the benefits of these methods of providing incentives for improving care. We measured changes in adherence to 10 individual and 4 composite measures of quality over a period of 2 years at 613 hospitals that voluntarily reported information about the quality of care through a national public-reporting initiative, including 207 facilities that simultaneously participated in a pay-for-performance demonstration project funded by the Centers for Medicare and Medicaid Services; we then compared the pay-for-performance hospitals with the 406 hospitals with public reporting only (control hospitals). We used multivariable modeling to estimate the improvement attributable to financial incentives after adjusting for baseline performance and other hospital characteristics. As compared with the control group, pay-for-performance hospitals showed greater improvement in all composite measures of quality, including measures of care for heart failure, acute myocardial infarction, and pneumonia and a composite of 10 measures. Baseline performance was inversely associated with improvement; in pay-for-performance hospitals, the improvement in the composite of all 10 measures was 16.1% for hospitals in the lowest quintile of baseline performance and 1.9% for those in the highest quintile (P<0.001). After adjustments were made for differences in baseline performance and other hospital characteristics, pay for performance was associated with improvements ranging from 2.6 to 4.1% over the 2-year period. Hospitals engaged in both public reporting and pay for performance achieved modestly greater improvements in quality than did hospitals engaged only in public reporting. Additional research is required to determine whether different incentives would stimulate more improvement and whether the benefits of these programs outweigh their costs.New England Journal of Medicine 02/2007; 356(5):486-96. DOI:10.1056/NEJMsa064964 · 54.42 Impact Factor
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ABSTRACT: Despite substantial enthusiasm among insurers and federal policy makers for pay-for-performance incentives, little is known about the current scope of these incentives or their influence on the delivery of care. To assess the scope and magnitude of pay-for-performance (P4P) incentives among physician groups and to examine whether such incentives are associated with quality improvement initiatives. Structured telephone survey of leaders of physician groups delivering primary care in Massachusetts. ASSESSED METHODS: Prevalence of P4P incentives among physician groups tied to specific measures of quality or utilization and prevalence of physician group quality improvement initiatives. Most group leaders (89%) reported P4P incentives in at least 1 commercial health plan contract. Incentives were tied to performance on Health Employer Data and Information Set (HEDIS) quality measures (89% of all groups), utilization measures (66%), use of information technology (52%), and patient satisfaction (37%). Among the groups with P4P and knowledge of all revenue streams, the incentives accounted for 2.2% (range, 0.3%-8.8%) of revenue. P4P incentives tied to HEDIS quality measures were positively associated with groups' quality improvement initiatives (odds ratio, 1.6; P = .02). Thirty-six percent of group leaders with P4P incentives reported that they were very important or moderately important to the group's financial success. P4P incentives are now common among physician groups in Massachusetts, and these incentives most commonly reward higher clinical quality or lower utilization of care. Although the scope and magnitude of incentives are still modest for many groups, we found an association between P4P incentives and the use of quality improvement initiatives.The American journal of managed care 06/2007; 13(5):249-55. · 2.17 Impact Factor