Plastic Surgeon Financial Compensation-Incentivization Models in Surgical Care Delivery: The Past, Present, and Future.

BACKGROUND: Surgeons are critical for the success of any health care enterprise. However, few studies have examined the potential impact of value-based care on surgeon compensation. METHODS: This review presents value-based financial incentive models that will shape the future of surgeon compensation. The following incentivization models will be discussed: pay-for-reporting, pay-for-performance, pay-for-patient-safety, bundled payments, and pay-for-academic-productivity. Moreover, the authors suggest the application of the congruence model-a model developed to help business leaders understand the interplay of forces that shape the performance of their organizations-to determine surgeon compensation methods applicable in value-based care-centric environments. RESULTS: The application of research in organizational behavior can assist health care leaders in developing surgeon compensation models optimized for value-based care. Health care leaders can utilize the congruence model to determine total surgeon compensation, proportion of compensation that is short term versus long term, proportion of compensation that is fixed versus variable, and proportion of compensation based on seniority versus performance. CONCLUSION: This review provides a framework extensively studied by researchers in organizational behavior that can be utilized when designing surgeon financial compensation plans for any health care entity shifting toward value-based care.

Association between specialist compensation and Accountable Care Organization performance.

OBJECTIVE: To determine if Medicare Shared Savings Program Accountable Care Organizations (ACOs) using cost reduction measures in specialist compensation demonstrated better performance. DATA SOURCES: National, cross-sectional survey data on ACOs (2013-2015) linked to public-use data on ACO performance (2014-2016). STUDY DESIGN: We compared characteristics of ACOs that did and did not report use of cost reduction measures in specialist compensation and determined the association between using this approach and ACO savings, outpatient spending, and specialist visit rates. PRINCIPAL FINDINGS: Of 160 ACOs surveyed, 26 percent reported using cost reduction measures to help determine specialist compensation. ACOs using cost reduction in specialist compensation were more often physician-led (68.3 vs 49.6 percent) and served higher-risk patients (mean Hierarchical Condition Category score 1.09 vs 1.05). These ACOs had similar savings per beneficiary year (adjusted difference $82.6 [95% CI -77.9, 243.1]), outpatient spending per beneficiary year (-24.0 [95% CI -248.9, 200.8]), and specialist visits per 1000 beneficiary years (369.7 [95% CI -9.3, 748.7]). CONCLUSION: Incentivizing specialists on cost reduction was not associated with ACO savings in the short term. Further work is needed to determine the most effective approach to engage specialists in ACO efforts.

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.

A Structured Compensation Plan Results in Equitable Physician Compensation: A Single-Center Analysis.

OBJECTIVE: To assess adherence to and individual or systematic deviations from predicted physician compensation by gender or race/ethnicity at a large academic medical center that uses a salary-only structured compensation model incorporating national benchmarks and clear standardized pay steps and increments. PARTICIPANTS AND METHODS: All permanent staff physicians employed at Mayo Clinic medical practices in Minnesota, Arizona, and Florida who served in clinical roles as of January 2017. Each physician's pay, demographics, specialty, full-time equivalent status, benchmark pay for the specialty, leadership role(s), and other factors that may influence compensation within the plan were collected and analyzed. For each individual, the natural log of pay was used to determine predicted pay and 95% CI based on the structured compensation plan, compared with their actual salary. RESULTS: Among 2845 physicians (861 women, 722 nonwhites), pay equity was affirmed in 96% (n=2730). Of the 80 physicians (2.8%) with higher and 35 (1.2%) with lower than predicted pay, there was no interaction with gender or race/ethnicity. More men (31.4%; 623 of 1984) than women (15.9%; 137 of 861) held or had held a compensable leadership position. More men (34.7%; 688 of 1984) than women (20.5%; 177 of 861) were represented in the most highly compensated specialties. CONCLUSION: A structured compensation model was successfully applied to all physicians at a multisite large academic medical system and resulted in pay equity. However, achieving overall gender pay equality will only be fully realized when women achieve parity in the ranks of the most highly compensated specialties and in leadership roles.

Effect of financial incentives on breast, cervical and colorectal cancer screening delivery rates: Results from a systematic literature review.

Preventive care, such as screening, is important for reducing the risk of cancer, a leading cause of death worldwide. Indeed, some type of cancers are detected through screening programs, which in most countries run for colorectal, breast, and cervical cancers. In this context, general practitioners play a key role in increasing the participation rate in cancer screening programs. To improve cancer screening delivery rates, performance incentives have increasingly been implemented in primary care by healthcare payers and organizations in different countries. The effects of these tools are still not clear. We conducted a systematic literature review in order to answer the following research question: What is the evidence in the literature for the effects of financial incentives on the delivery rates of breast, cervical and colorectal cancer screening in general practice? We performed a literature search in Web of Science, PubMed, Cochrane Library and Google Scholar, according to the PRISMA guidelines. 18 studies were selected, classified and discussed according to the health preventive services investigated. Most of studies showed partial or no effects of financial incentives on breast and cervical cancer screening delivery rates. Few positive or partial effects were found regarding colorectal cancer screening. Ongoing monitoring of incentive programs is critical to determining the effectiveness of financial incentives and their effects on the improvement of cancer screening delivery rates.

Production of physician services under fee-for-service and blended fee-for-service: Evidence from Ontario, Canada.

We examine family physicians' responses to financial incentives for medical services in Ontario, Canada. We use administrative data covering 2003-2008, a period during which family physicians could choose between the traditional fee for service (FFS) and blended FFS known as the Family Health Group (FHG) model. Under FHG, FFS physicians are incentivized to provide comprehensive care and after-hours services. A two-stage estimation strategy teases out the impact of switching from FFS to FHG on service production. We account for the selection into FHG using a propensity score matching model, and then we use panel-data regression models to account for observed and unobserved heterogeneity. Our results reveal that switching from FFS to FHG increases comprehensive care, after-hours, and nonincentivized services by 3%, 15%, and 4% per annum. We also find that blended FFS physicians provide more services by working additional total days as well as the number of days during holidays and weekends. Our results are robust to a variety of specifications and alternative matching methods. We conclude that switching from FFS to blended FFS improves patients' access to after-hours care, but the incentive to nudge service production at the intensive margin is somewhat limited.

Meaningful Use: Does Physician Participation Move the Needle on Quality Metrics?

INTRODUCTION: To determine the association between pattern of participation in the Meaningful Use (MU) initiative and self-reported clinical quality metrics. METHODS: We used state-level Medicaid electronic health record (EHR) incentive program data to categorize physicians based on receipt of MU payments (single year vs. multiple years) and self-reported quality metrics from 2011 to 2016. RESULTS: Among 4,198 participating physicians, only 36% received more than one EHR incentive payment. Physicians participating for a single year had better cancer-screening metrics. By comparison, physicians who participated for multiple years reported better medication-related metrics and chronic disease management metrics. CONCLUSIONS: Nature of participation may have varying degrees of influence on types of clinical quality metrics. Sustained participation may support management of chronic conditions. Administrative claims data will help to elucidate our findings.

Variation in Physician-Specific Episode Payments for Major Cancer Surgery and Implications for the Merit-Based Incentive Program.

BACKGROUND: Nearly 1.5 million clinicians in the United States will be affected by Centers for Medicare and Medicaid Services' (CMS) new payment program, the Merit-based Incentive Program (MIPS), where clinicians will be penalized or rewarded based on the health care expenditures of their patients. We therefore examined expenditures for major cancer surgery to understand physician-specific variation in episode payments. METHODS: We used Surveillance, Epidemiology and End Results-Medicare data to identify patients aged 66-99 y who underwent a prostatectomy, nephrectomy, lung, or colorectal resection for cancer from 2008 to 2012. We calculated 90-d episode payments, attributed each episode to a physician, and evaluated physician-level payment variation. Next, we determined which component (index admission, readmission, physician services, postacute care, hospice) drove differences in payments. Finally, we evaluated payments by geographic region, number of comorbidities, and cancer stage. RESULTS: We identified 39,109 patients who underwent surgery by 1 of 7182 providers. There was wide variation in payments for each procedure (prostatectomy: $7046-$40,687; nephrectomy: $8855-$82,489; lung resection: $11,167-$223,467; colorectal resection: $9711-$199,480). The largest component difference in episode payments varied by condition: physician payments for prostatectomy (29%), postacute care for nephrectomy (38%) and colorectal resections (38%), and index hospital admission for lung resections (43%) but were fairly stable across region, comorbidity number, and cancer stage. CONCLUSIONS: For patients undergoing major cancer surgery, 90-d episode payments vary widely across surgeons. The components driving such variation differ by condition but remain stable across region, number of comorbidities, and cancer stage. These data suggest that programs to reduce specific component payments may have advantages over those targeting individual physicians for decreasing health care expenditures.

Association between Hospitalist Productivity Payments and High-Value Care Culture.

BACKGROUND: Given the national emphasis on affordability, healthcare systems expect that their clinicians are motivated to provide high-value care. However, some hospitalists are reimbursed with productivity bonuses, and little is known about the effects of these reimbursements on the local culture of high-value care delivery. OBJECTIVE: To evaluate if hospitalist reimbursement models are associated with high-value culture in university, community, and safety-net hospitals. DESIGN, SETTING, PATIENTS: Internal medicine hospitalists from 12 hospitals across California completed a cross-sectional survey assessing their perceptions of high-value care culture within their institutions. Sites represented university, community, and safety-net centers with different performances as reflected by the Centers of Medicare and Medicaid Service's Value-based Purchasing (VBP) scores. MEASUREMENT: Demographic characteristics and High-Value Care Culture Survey (HVCCSTM) scores were evaluated using descriptive statistics, and associations were assessed through multilevel linear regression. RESULTS: Of the 255 hospitalists surveyed, 147 (57.6%) worked in university hospitals, 85 (33.3%) in community hospitals, and 23 (9.0%) in safety-net hospitals. Across all 12 sites, 166 (65.1%) hospitalists reported payment with salary or wages, and 77 (30.2%) with salary plus productivity adjustments. The mean HVCCS score was 50.2 (SD 13.6) on a 0-100 scale. Hospitalists reported lower mean HVCCS scores if they reported payment with salary plus productivity (ß = -6.2, 95% CI -9.9 to -2.5) than if they reported payment with salary or wages. CONCLUSIONS: Hospitalists paid with salary plus productivity reported lower high-value care culture scores for their institutions than those paid with salary or wages. High-value care culture and clinician reimbursement schemes are potential targets of strategies for improving quality outcomes at low cost.

Effects of episode-based payment on health care spending and utilization: Evidence from perinatal care in Arkansas.

We study how physicians respond to financial incentives imposed by episode-based payment (EBP), which encourages lower spending and improved quality for an entire episode of care. Specifically, we study the impact of the Arkansas Health Care Payment Improvement Initiative, a multi-payer program that requires providers to enter into EBP arrangements for perinatal care, covering the majority of births in the state. Unlike fee-for-service reimbursement, EBP holds physicians responsible for all care within a discrete episode, rewarding physicians for efficient use of their own services and for efficient management of other health care inputs. In a difference-in-differences analysis of commercial claims, we find that perinatal spending in Arkansas decreased by 3.8% overall under EBP, compared to surrounding states. The decrease was driven by reduced spending on non-physician health care inputs, specifically the prices paid for inpatient facility care. We additionally find a limited improvement in quality of care under EBP.

The Effect of Clinical Pharmacists on Readmission Rates of Heart Failure Patients in the Accountable Care Environment.

BACKGROUND: Recent changes in the health care delivery landscape have expanded opportunities for clinical pharmacists in the ambulatory care setting. This article describes the successful integration of a clinical pharmacist-led chronic disease management service in a patient-centered medical home (PCMH) and accountable care organization (ACO) environment. PROGRAM DESCRIPTION: In 2008, the year before PCMH implementation, 36% of patients who were hospitalized at Advocate Trinity Hospital for a heart failure exacerbation were readmitted within 30 days of their hospital stay for heart failure exacerbation. This high rate of heart failure hospital readmissions, compared with national standards, drove the implementation of the PCMH at Advocate Medical Group - Southeast Center (AMG-SE), the adjoining outpatient medical clinic. A clinical pharmacist was added to the health care team to help achieve the collective goal of improving patient outcomes and decreasing hospitalizations. OBSERVATIONS: From November 1, 2009, through August 30, 2010, the clinical pharmacist conducted visits and intervened in the care of 111 chronic heart failure patients. A pre/post analysis of those 111 patients during the 10 months before and after the integration of the clinical pharmacist showed that those patients were hospitalized 63 times in the 10 months before having regularly scheduled visits with the clinical pharmacist and 30 times in the 10 months after establishing care. This reduction from 63 to 30 visits translated to an approximate 50% decrease in heart failure hospitalizations in patients being followed by the clinical pharmacist within the first 10 months. Once the clinical pharmacist became better integrated into the workflow through development of rapport with the medical team, the outcomes improved further. In an 18-month analysis from May 1, 2010, through November 30, 2011, only 2% of patients (3 of 153) designated as high-risk patients managed by the clinical pharmacist had a 30-day readmission for heart failure exacerbation. IMPLICATIONS: Outcomes-based models have expanded opportunities for clinical pharmacist involvement and can provide unique reimbursement options. Demonstration of cost savings and an improvement in quality measures are paramount to establishing and justifying the clinical pharmacist's role in a team-based model of care. DISCLOSURES: No outside funding supported this research. The authors have no conflicts of interest to disclose.

Investigating the impact of primary care payments on underdiagnosis in dementia: A difference-in-differences analysis.

OBJECTIVE: In England, two primary care incentive schemes were introduced to increase dementia diagnosis rates to two-thirds of expected levels. This study assesses the effectiveness of these schemes. METHODS: We used a difference-in-differences framework to analyse the individual and collective impacts of the incentive schemes: (1) Directed Enhanced Service 18 (DES18: facilitating timely diagnosis of and support for dementia) and (2) the Dementia Identification Scheme (DIS). The dataset included 7529 English general practices, of which 7142 were active throughout the 10-year study period (April 2006 to March 2016). We controlled for a range of factors, including a contemporaneous hospital incentive scheme for dementia. Our dependent variable was the percentage of expected cases that was recorded on practice dementia registers (the "rate"). RESULTS: From March 2013 to March 2016, the mean rate rose from 51.8% to 68.6%. Both DES18 and DIS had positive and significant effects. In practices participating in the DES18 scheme, the rate increased by 1.44 percentage points more than the rate for non-participants; DIS had a larger effect, with an increase of 3.59 percentage points. These combined effects increased dementia registers nationally by an estimated 40 767 individuals. Had all practices fully participated in both schemes, the corresponding number would have been 48 685. CONCLUSION: The primary care incentive schemes appear to have been effective in closing the gap between recorded and expected prevalence of dementia, but the hospital scheme had no additional discernible effect. This study contributes additional evidence that financial incentives can motivate improved performance in primary care.

Take the money and run? Redemption of a gift card incentive in a clinician survey.

BACKGROUND: Clinician surveys provide critical information about many facets of health care, but are often challenging to implement. Our objective was to assess use by participants and non-participants of a prepaid gift card incentive that could be later reclaimed by the researchers if unused. METHODS: Clinicians were recruited to participate in a mailed or online survey as part of a study to characterize women's primary health care provider attitudes towards breast and cervical cancer screening guidelines and practices (n = 177). An up-front incentive of a $50 gift card to a popular online retailer was included with the study invitation. Clinicians were informed that the gift card would expire if it went unused after 4 months. Outcome measures included use of gift cards by participants and non-participants and comparison of hypothetical costs of different incentive strategies. RESULTS: 63.5% of clinicians who responded to the survey used the gift card, and only one provider who didn't participate used the gift card (1.6%). Many of those who participated did not redeem their gift cards (36.5% of respondents). The price of the incentives actually claimed totaled $3700, which was less than half of the initial outlay. Since some of the respondents did not redeem their gift cards, the cost of incentives was less than it might have been if we had provided a conditional incentive of $50 to responders after they had completed the survey. CONCLUSIONS: Redeemable online gift card codes may provide an effective way to motivate clinicians to participate in surveys.

The true impact of the French pay-for-performance program on physicians' benzodiazepines prescription behavior.

OBJECTIVES: The French pay-for-performance (P4P) contract CAPI implemented by the national health insurance included a target-goal which aims at reducing benzodiazepines prescriptions. In this investigation, we would like to assess whether: (1) the general practitioners (GPs) having signed P4P contract obtain better results regarding the target-goal than non-signatories; (2) (part of) this progression is due to the CAPI contract itself (tentative measurement of a "causal effect"); (3) (part of) the money spent on this P4P incentive can be self-financed with the amount of pharmaceuticals saved. METHODS: We matched cross-sectional and longitudinal data including 4622 French GPs from June 2011 to December 2012. A treatment effect model using instrumental variables was performed to take into account potential self-selection issue in signing. After having identified the NET impact of the P4P, we calculate the cost of an avoided benzodiazepines treatment. RESULTS: In our study, GPs who have signed the CAPI contract (36 % of the sample) are more numerous in achieving benzodiazepines target goal than non-signatories: 90.7 vs. 85.5 %. After controlling for the self-selection bias, the propensity of GPs to achieve the benzodiazepines target is only 0.31 % higher for signatories than for their non-signing counterparts-estimate for June 2012, which yields a statistically significant gap. Our economic analysis demonstrates that the CAPI contract does not allow savings, but presents in 2012 a NET cost of 93.6€ per avoided benzodiazepines treatment (291€ in 2011). CONCLUSIONS: The P4P contract has a positive but modest impact on the achievement of GPs regarding benzodiazepines indicator.

The use of financial incentives in Australian general practice.

OBJECTIVE: To examine the uptake of financial incentive payments in general practice, and identify what types of practitioners are more likely to participate in these schemes. DESIGN AND SETTING: Analysis of data on general practitioners and GP registrars from the Medicine in Australia - Balancing Employment and Life (MABEL) longitudinal panel survey of medical practitioners in Australia, from 2008 to 2011. MAIN OUTCOME MEASURES: Income received by GPs from government incentive schemes and grants and factors associated with the likelihood of claiming such incentives. RESULTS: Around half of GPs reported receiving income from financial incentives in 2008, and there was a small fall in this proportion by 2011. There was considerable movement into and out of the incentives schemes, with more GPs exiting than taking up grants and payments. GPs working in larger practices with greater administrative support, GPs practising in rural areas and those who were principals or partners in practices were more likely to use grants and incentive payments. CONCLUSIONS: Administrative support available to GPs appears to be an increasingly important predictor of incentive use, suggesting that the administrative burden of claiming incentives is large and not always worth the effort. It is, therefore, crucial to consider such costs (especially relative to the size of the payment) when designing incentive payments. As market conditions are also likely to influence participation in incentive schemes, the impact of incentives can change over time and these schemes should be reviewed regularly.

A Comparison of the J-1 Visa Waiver and Loan Repayment Programs in the Recruitment and Retention of Physicians in Rural Nebraska.

PURPOSE: There is a dearth of literature evaluating the effectiveness of programs aimed at recruiting and retaining physicians in rural Nebraska. Taking advantage of the Nebraska Health Professional Tracking System, this study attempts to comparatively assess the effectiveness of the J-1 visa waiver and state loan repayment programs in the recruitment and retention of physicians in rural Nebraska. METHODS: A mixed methods approach was used. We tracked 240 physicians who enrolled in the J-1 visa waiver and state loan repayment programs between 1996 and 2012 until 2013. In addition, key informant interviews were conducted to obtain perspectives on the recruitment and retention of physicians in rural Nebraska through the 2 programs. FINDINGS: Results from multilevel survival regression analysis indicated that physicians enrolled in the J-1 visa waiver program were more likely to leave rural Nebraska when compared with those enrolled in the state loan repayment program. Participants in the qualitative study, however, cautioned against declaring one program as superior over the other, given that the 2 programs addressed different needs for different communities. In addition, results suggested that fostering the integration of physicians and their families into rural communities might be a way of enhancing retention, regardless of program. CONCLUSION: The findings from this study highlight the complexity of recruitment and retention issues in rural Nebraska and suggest the need for more holistic and family-centered approaches to addressing these issues.

The tougher the better: an economic analysis of increased payment thresholds on the performance of general practices.

We investigate whether and how a change in performance-related payment motivated General Practitioners (GPs) in Scotland. We evaluate the effect of increases in the performance thresholds required for maximum payment under the Quality and Outcomes Framework in April 2006. A difference-in-differences estimator with fixed effects was employed to examine the number of patients treated under clinical indicators whose payment schedules were revised and to compare these with the figures for those indicators whose schedules remained unchanged. The results suggest that the increase in the maximum performance thresholds increased GPs' performance by 1.77% on average. Low-performing GPs improved significantly more (13.22%) than their high-performing counterparts (0.24%). Changes to maximum performance thresholds are differentially effective in incentivising GPs and could be used further to raise GPs' performance across all indicators.

Physician financial incentives and care for the underserved in the United States.

OBJECTIVES: To estimate: (1) the percentage of physicians whose compensation is variable; (2) the frequency at which performance incentives for productivity, care quality, patient satisfaction, and resource use were used to determine compensation; and (3) how much incentives differ for physicians who serve greater percentages of patients who are Medicaid-insured, racial/ethnic minorities, or who face language barriers, versus those who do not. STUDY DESIGN: Cross-sectional study of 3234 nationally representative physicians responding to the 2008 Center for Studying Health System Change's Health Tracking Physician Survey (HTPS). METHODS: We examined the degree to which practices' percentage of Medicaid revenues and physicians' panel characteristics were associated with physicians' financial incentives using χ² statistics and multivariate logistic regression (adjusting for physician specialty, practice type, and capitation levels, and area-based factors). RESULTS: Compensation was variable for 69% of respondents, was most frequently tied to productivity (68%), and less often to care quality (19%), patient satisfaction (21%), or resource use (14%). Physicians were significantly less likely to report variable compensation if the percentage Medicaid revenues was 50% or more (adjusted odds ratio [OR] 0.73, 95% confidence interval [CI], 0.57-0.95) or if physician panels were at least 50% Hispanic (adjusted OR 0.74, 95% CI, 0.56-0.99). However, physicians were significantly more likely to report use of all 4 performance incentives if percentage of Medicaid revenues was 6% to 24%. CONCLUSIONS: Physicians report different types of financial incentives designed to alter care quality and quantity; incentive types differ by the degree that practices derive revenues from Medicaid or serve Hispanic patients. Further investigation is needed to understand how to align financial incentives with disparity-reduction efforts.