Effect of Payment Incentives on Cancer Screening in Ontario Primary Care

Abstract

PURPOSE There is limited evidence for the effectiveness of pay for performance despite its widespread use. We assessed whether the introduction of a pay-forperformance scheme for primary care physicians in Ontario, Canada, was associated with increased cancer screening rates and determined the amounts paid to physicians as part of the program. METHODSWe performed a longitudinal analysis using administrative data to determine cancer screening rates and incentive costs in each fiscal year from 1999/2000 to 2009/2010. We used a segmented linear regression analysis to assess whether there was a step change or change in screening rate trends after incentives were introduced in 2006/2007. We included all Ontarians eligible for cervical, breast, and colorectal cancer screening. RESULTSWe found no significant step change in the screening rate for any of the 3 cancers the year after incentives were introduced. Colon cancer screening was increasing at a rate of 3.0% (95% CI, 2.3% to 3.7%) per year before the incentives were introduced and 4.7% (95% CI, 3.7% to 5.7%) per year after. The cervical and breast cancer screening rates did not change significantly from year to year before or after the incentives were introduced. Between 2006Between /2007Between and 2009Between /2010.3 million, $31.3 million, and $50.0 million were spent on financial incentives for cervical, breast, and colorectal cancer screening, respectively. CONCLUSIONSThe pay-for-performance scheme was associated with little or no improvement in screening rates despite substantial expenditure. Policy makers should consider other strategies for improving rates of cancer screening. INTRODUCTIONG overnments around the world are trying to align physician financial incentives with desired health system goals. In the United States, the National Commission on Physician Payment Reform recently stated that " [o]ur nation cannot control runaway medical spending without fundamentally changing how physicians are paid."1 Over the last decade, pay for performance has been seen by many as the most promising approach to reducing health system cost and improving quality.2 Critics have questioned whether pay for performance can deliver on its promise, however, citing issues with measurement, target-setting, non-financial barriers to optimizing care, and intrinsic physician motivation. [3][4][5] Reducing morbidity and mortality through cancer screening is an important component of primary care. Screening for cervical cancer 6 and colorectal cancer 7 is generally regarded as cost-effective. Screening for breast cancer via mammography is more controversial, [8][9][10] but is still widely recommended by clinical practice guidelines.11,12 Nevertheless, a substantial proportion of individuals do not receive recommended cancer screening. [13][14][15][16] It is unclear whether pay for performance can shrink gaps in preventive care specifically 17,18 or primary care more generally. 19We evaluated a large-scale pay-for-performance scheme introduced in Ontario in 2006 and a...

A population-based analysis of incentive payments to primary care physicians for the care of patients with complex disease

“…28,29 Research to date, largely from the United Kingdom and United States, has provided mixed evidence of the effectiveness of these programs. 24,[30][31][32][33][34] Studies of Ontario's pay-forperformance initiatives showed modest improvements in delivery of some preventive services 35,36 and no change in management of patients with diabetes. 37 The Ontario picture is complicated by the fact that physician payment mechanisms were also modified, which may have influenced both care for patients with chronic disease 38 and uptake of incentives.…”

Small-area variation in screening for cancer, glucose and cholesterol in Ontario: a cross-sectional study

“…Studies of financial incentives to physicians for screening and primary care reforms between the years 2000 and 2009 have not had an impact on screening participation. [6][7][8][9] There is strong evi dence indicating that primary care practices could do better in encouraging participation among those who actually attend the practices.…”

“…[1][2][3][4][5] Uptake of these tests in Ontario is not optimal, 6 despite efforts aimed at "average" individuals, including promotion of cancerscreening programs in English and French, 7 financial incentives to primary care physicians for cancer screening, 8 increasing numbers of physicians, the introduction of patient enrolment models and other enhanced practice models for primary care. 9 There is no coordination or integration of participation across these cancer screening tests, or with glucose and cholesterol screening.…”

Longitudinal evaluation of physician payment reform and team-based care for chronic disease management and prevention

“…20 We calculated cancer screening rates using service claims. We determined eligibility for and completion of screening on the basis of clinical practice guideline recommendations and the cancer screening bonuses available to medical home physicians, as we have done previously 21 (Appendix 3, available at www.cmaj.ca/lookup/ suppl/doi:10.1503/cmaj.150579/-/DC1).…”