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...