Current Interventional Radiology-Related Benchmarked Clinical Quality Measures Are Less Likely to be "Capped" Than Diagnostic Radiology Clinical Quality Measures.

In the merit-based incentive payment system (MIPS), quality measures are considered topped out if national median performance rates are ≥95%. Quality measures worth 10 points can be capped at 7 points if topped out for ≥2 years. This report compares the availability of diagnostic radiology (DR)-related and interventional radiology (IR)-related measures worth 10 points. A total of 196 MIPS clinical quality measures were reviewed on the Center for Medicare and Medicaid Services MIPS website. There are significantly more IR-related measures worth 10 points than DR measures (2/9 DR measures vs 9/12 IR measures; P = .03), demonstrating that clinical IR services can help mixed IR/DR groups maximize their Center for Medicare and Medicaid Services payment adjustment.

Integration of cardiologists with hospitals: Effects on physician compensation and productivity.

BACKGROUND: Hospital-physician vertical integration involving employment of physicians has increased considerably over the last decade. Cardiologists are one group of specialists being increasingly employed by hospitals. Although hospital-physician integration has the potential to produce economic and societal benefits, there is concern that this consolidation may reduce competition and concentrate bargaining power among providers. In addition, hospitals may be motivated to offer cardiologists higher compensation and reduced workloads as an incentive to integrate. PURPOSE: The aim of the study was to determine if there are differences in compensation and clinical productivity, measured by work relative value units (RVUs), for cardiologists as they transition from being independent practitioners to being employed by hospitals. METHODOLOGY/APPROACH: This study was a quantitative, retrospective, longitudinal analysis, comparing the compensation and work RVUs of integrated cardiologists to their compensation and work RVUs as independent cardiologists. Data from the MedAxiom Annual Survey from 2010 to 2014 were used. Participants included 4,830 unique cardiologists that provided 13,642 pooled physician-year observations, with ownership status, compensation, work (RVUs), and other characteristics as variables for analysis. RESULTS: Results from the multivariate regressions indicate that average compensation for cardiologists increases by $129,263.1 (p < .001) when they move from independent to integrated practice. At the same time, physician work RVUs decline by 398.04 (p = .01). CONCLUSION: Our findings support the conjecture that hospitals may be offering higher pay and lower workloads to incentivize cardiologists to integrate. PRACTICE IMPLICATIONS: Although hospitals may have goals of quality improvement and lower costs, such goals may presently be secondary to service line growth and increased market power. There is reason to be cautious about some of the implications of hospital integration of cardiologists.

Impact of secondary care financial incentives on the quality of physical healthcare for people with psychosis: a longitudinal controlled study.

BACKGROUND: Concerns have repeatedly been expressed about the quality of physical healthcare that people with psychosis receive. AIMS: To examine whether the introduction of a financial incentive for secondary care services led to improvements in the quality of physical healthcare for people with psychosis. METHOD: Longitudinal data were collected over an 8-year period on the quality of physical healthcare that people with psychosis received from 56 trusts in England before and after the introduction of the financial incentive. Control data were also collected from six health boards in Wales where a financial incentive was not introduced. We calculated the proportion of patients whose clinical records indicated that they had been screened for seven key aspects of physical health and whether they were offered interventions for problems identified during screening. RESULTS: Data from 17 947 people collected prior to (2011 and 2013) and following (2017) the introduction of the financial incentive in 2014 showed that the proportion of patients who received high-quality physical healthcare in England rose from 12.85% to 31.65% (difference 18.80, 95% CI 17.37-20.21). The proportion of patients who received high-quality physical healthcare in Wales during this period rose from 8.40% to 13.96% (difference 5.56, 95% CI 1.33-10.10). CONCLUSIONS: The results of this study suggest that financial incentives for secondary care mental health services are associated with marked improvements in the quality of care that patients receive. Further research is needed to examine their impact on aspects of care that are not incentivised.

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.

Facility-Based Measurement in the Merit-Based Incentive Payment System: A Potential Safety Net for Which Most Radiologists Will Be Eligible.

OBJECTIVE. The purpose of this study was to assess the percentage and characteristics of radiologists who meet criteria for facility-based measurement in the Merit-Based Incentive Payment System (MIPS). MATERIALS AND METHODS. The Provider Utilization and Payment Data: Physician and Other Supplier Public Use File was used to identify radiologists who bill 75% or more of their Medicare Part B claims in the facility setting. RESULTS. Among 31,217 included radiologists nationwide, 71.0% met the eligibility criteria for facility-based measurement as individuals in MIPS. The percentage of predicted eligibility was slightly higher for male than female radiologists (72.9% vs 64.5%). The percentage decreased slightly with increasing years in practice (from 78.8% for radiologists with < 10 years in practice to 67.3% for radiologists with ≥ 25 years in practice). The eligibility percentage was also higher for radiologists in rural as opposed to urban practices (81.6% vs 71.3%) and in academic as opposed to nonacademic practices (77.2% vs 70.3%). However, the percentages were similar across practices of varying sizes. There was also a greater degree of heterogeneity by state, ranging from 50.9% in Minnesota to 94.0% in West Virginia. By overall geographic region, the percentage of predicted eligibility was lowest in the Northeast (64.7%) and highest in the Midwest (78.3%). A higher percentage of generalists met the 75% facility-based threshold than did subspecialists (77.3% vs 65.4%). When stratified by subspecialty, however, facility-based eligibility was lowest for musculoskeletal radiologists (38.1%) and breast imagers (45.1%) and highest for cardiothoracic radiologists (85.1%). For other subspecialties, predicted eligibility ranged from 66.0% to 77.8%. CONCLUSION. Most radiologists will be eligible for facility-based reporting for MIPS in 2019, with some variation by demographic and specialty characteristics. The facility-based option provides a safety net for radiologists who face challenges accessing hospital data for reporting quality measures. In general, radiologists should not alter their current MIPS strategy but should instead consider facility-based measurement as a contingency plan that could result in a higher final score.

Financial incentives and physician prescription behavior: Evidence from dispensing regulations.

In many health care markets, physicians can respond to changes in reimbursement schemes by changing the volume (volume response) and the composition of services provided (substitution response). We examine the relative importance of these two behavioral responses in the context of physician drug dispensing in Switzerland. We find that dispensing increases drug costs by 52% for general practitioners and 56% for specialists. This increase is mainly due to a volume increase. The substitution response is negative on average, but not significantly different from zero for large parts of the distribution. In addition, our results reveal substantial effect heterogeneity.

The Effect of a Primary Care Provider Incentive Program on Pediatric Emergency Medicine Visits.

OBJECTIVE: The aim of the study was to analyze the effect of a financial incentive program targeting primary care providers (PCPs) with the goal of decreasing emergency department (ED) utilization. METHODS: We performed a retrospective cohort analysis in a single health maintenance organization comparing ED visit/1000 member-months before and after the physician incentive program in 2009. We compared the median ED visit rate between physicians who did (PIP) and did not participate (non-PIP) from 2009 to 2012. We used 2008 data as a baseline study period to compare the ED visit rate between PIP and non-PIP providers to detect any inherent difference between the 2 groups. RESULTS: A total of 1376 PCPs were enrolled. A total of US $18,290,817 was spent in total on incentives. Overall, the median ED visit rate for all providers was statistically significantly lower during the study period (baseline period, study period: 56.36 ED visits/1000 member-months vs 45.82, respectively, P < 0.001). During the baseline period in our fully adjusted linear regression for degree, specialty, education, and board status, PIP versus non-PIP visits were not statistically significantly different (P = 0.17). During the study period in our fully adjusted model, we found that PIP had statistically significant fewer ED visits compared with non-PIP (P = 0.02). In a subgroup analysis of providers who did and did not receive an incentive payment, in the fully adjusted linear regression, providers who received any payment had statistically significant fewer ED visits/1000 member-months (P < 0.001). In addition, we found in the fully adjusted analysis that those providers who received at least 1 incentive payment for meeting after-hours criteria had statistically significantly fewer ED visits/1000 member-months (P < 0.001). CONCLUSIONS: A financial incentive program to provide PCPs with specific targets and goals to decrease pediatric ED utilization can decrease ED visits.

Factors that Predict Failure to Meet Merit-Based Incentive Payment System Quality Measures for Asymptomatic Carotid Endarterectomy.

BACKGROUND: The Physician Quality Reporting System (PQRS) created by the Centers for Medicare and Medicaid Services financially penalizes providers who fail to meet expected quality of care measures. The purpose of this study is to evaluate the factors that predict failure to meet PQRS measures for carotid endarterectomy (CEA). METHODS: PQRS measure 260 (discharge by postoperative day 2 following CEA in asymptomatic patients) and 346 (rate of postoperative stroke or death following CEA in asymptomatic patients) were evaluated using hospital records from the state of Florida from 2008 to 2012. The impact of demographics, comorbidities, hospital factors, admission variables, and individual practitioner data upon timely discharge, and postoperative stroke and death. Odds ratios, 95% confidence intervals, and significance (P < 0.05) were determined through the development of a logistic regression model. Surgeons were identified by national provider identifier number, and practitioner data obtained from the American Medical Association Physician Masterfile. RESULTS: A total of 34,235 patient records and 701 providers were identified over the 5-year period. Significant negative predictors for PQRS measure 260 included weekend admission (odds ratio [OR], 2.9), Medicaid (OR, 2.4), surgeon historical postoperative stroke rate >2.0% (OR, 1.7), African-American race (OR, 2.0), and female gender (OR, 1.3). The presence of any of these factors was associated with a 13.5% rate of failure. The most significant negative predictor for PQRS measure 346 was surgeon postoperative stroke rate >2.0% (OR, 6.2 for stroke and OR, 29.0 for death). Surgeons in this underperforming group had worse outcomes compared to their peers despite having patients with fewer risk factors for poor outcomes. Surgeon specialty, board certification, and case volume do not impact either PQRS measures. CONCLUSIONS: Selected groups of patients and surgeons with a disproportionately high rate of postoperative stroke are at risk of failing to meet PQRS pay for performance quality measures. Awareness of these risk factors may help mitigate and minimize the risk of adversely impacting the value stream. Further evaluation of the causative factors that lead to surgeon underperformance could help to improve the quality of care.

Attitude towards working in rural areas: a cross-sectional survey of rural-oriented tuition-waived medical students in Shaanxi, China.

BACKGROUND: Attracting and recruiting health workers to work in rural areas is still a great challenge in China. The rural-oriented tuition-waived medical education (RTME) programme has been initiated and implemented in China since 2010. This study aimed to examine the attitudes of rural-oriented tuition-waived medical students (RTMSs) in Shaanxi towards working in rural areas and the related influencing factors. METHODS: A cross-sectional survey was conducted in 2015 among 232 RTMSs in two medical universities from the first group of students enrolled in the RTME programme in Shaanxi. Descriptive and analytical statistics were used for the data analyses. RESULTS: Of the 230 valid responses, 92.6% expressed their intentions of breaking the contract for working in rural township hospitals for 6 years after their graduation under the RTME programme. After the contract expired, only 1.3% intended to remain in the rural areas, 66.5% had no intention of remaining, and 32.2% were unsure. The factors related to a positive attitude among the RTMSs towards working in rural areas (no intention of breaking the contract) included being female, having a mother educated at the level of primary school or below, having a good understanding of the policy, having a good cognition of the value of rural medical work, and being satisfied with the policy. The factors related to a positive attitude of the RTMSs towards remaining in rural areas included being female, having a rural origin, having no regular family monthly income, having a father whose occupation was farmer, having a mother educated at the level of postsecondary or above, having the RTMSs be the final arbiter of the policy choice, having a good understanding of the policy, having a good cognition of the value of rural medical work, and being satisfied with the educational scheme. CONCLUSIONS: Related policy makers and health workforce managers may benefit from the findings of this study. Appropriate strategies should be implemented to stimulate the RTMSs' intrinsic motivation and improve their willingness to work in rural areas and to better achieve the objectives of RTME policy. Meanwhile, measures to increase the retention of RTMSs should also be advanced.

Exploring Attributes of High-Value Primary Care.

PURPOSE: Medicare's merit-based incentive payment system and narrowing of physician networks by health insurers will stoke clinicians' and policy makers' interest in care delivery attributes associated with value as defined by payers. METHODS: To help define these attributes, we analyzed 2009 to 2011 commercial health insurance claims data for more than 40 million preferred provider organization patients attributed to over 53,000 primary care practice sites. We identified sites ranking favorably on both quality and low total annual per capita health care spending ("high-value") and sites ranking near the median ("average-value"). Sites were selected for qualitative assessment from 64 high-value sites and 102 average-value sites with more than 1 primary care physician who delivered adult primary care and provided services to enough enrollees to permit meaningful spending and quality ranking. Purposeful sampling ensured regional diversity. Physicians experienced in primary care assessment and blinded to site rankings visited 12 high-value sites and 4 average-value sites to identify tangible attributes of care delivery that could plausibly explain a high ranking on value. RESULTS: Thirteen attributes of care delivery distinguished sites in the high-value cohort. Six attributes attained statistical significance: decision support for evidence-based medicine, risk-stratified care management, careful selection of specialists, coordination of care, standing orders and protocols, and balanced physician compensation. CONCLUSIONS: Awareness of care delivery attributes that distinguish their high-value peers may help physicians respond successfully to incentives from Medicare and private payers to lower annual health care spending and improve quality of care.

Sorting into payment schemes and medical treatment: A laboratory experiment.

In this study, we introduce the opportunity for physicians to sort into capitation or fee-for-service payment. Using a controlled medically framed laboratory experiment with a sequential within-subject design allows isolating sorting from incentive effects. We observe a strong preference for fee-for-service payment, which does not depend on subjects' prior experience with one of the two payment schemes. Further, we identify a significant sorting effect. Subjects choosing capitation deviate ex ante less from patient-optimal medical treatment than subjects who sort into fee-for-service payment. Particularly the latter become even less patient-oriented after introducing the choice option. Consequently, the opportunity to choose between fee-for-service and capitation payment worsens patient treatment, if at all. Our results hold for medical and for nonmedical students.

The effects of competition on medical service provision.

We explore how competition between physicians affects medical service provision. Previous research has shown that, without competition, physicians deviate from patient-optimal treatment under payment systems like capitation and fee-for-service. Although competition might reduce these distortions, physicians usually interact with each other repeatedly over time and only a fraction of patients switches providers at all. Both patterns might prevent competition to work in the desired direction. To analyze the behavioral effects of competition, we develop a theoretical benchmark that is then tested in a controlled laboratory experiment. Experimental conditions vary physician payment and patient characteristics. Real patients benefit from provision decisions made in the experiment. Our results reveal that, in line with the theoretical prediction, introducing competition can reduce overprovision and underprovision, respectively. The observed effects depend on patient characteristics and the payment system, though. Tacit collusion is observed and particularly pronounced with fee-for-service payment, but it appears to be less frequent than in related experimental research on price competition.

Getting Incentives Right? The Impact of Hospital Capitation Payment in Vietnam.

This paper evaluates the impact on cost and utilization of a shift from fee-for-service to capitation payment of district hospitals by Vietnam's social health insurance agency. Hospital fixed effects analysis suggests that capitation leads to reduced costs. Hospitals also increased service provision to the uninsured who continue to pay out-of-pocket on a fee-for-service basis. The study points to the need to anticipate unintended effects of payment reforms, especially in the context of a multiple purchaser system. Copyright © The World Bank Health Economics © 2015 John Wiley & Sons, Ltd.

The Effects of Introducing Mixed Payment Systems for Physicians: Experimental Evidence.

Mixed payment systems have become a prominent alternative to paying physicians through fee-for-service and capitation. While theory shows mixed payment systems to be superior, causal effects on physicians' behavior when introducing mixed systems are not well understood empirically. We systematically analyze the influence of fee-for-service, capitation, and mixed payment systems on physicians' service provision. In a controlled laboratory setting, we implement an exogenous variation of the payment method. Medical and non-medical students in the role of physicians in the lab (N = 213) choose quantities of medical services affecting patients' health outside the lab. Behavioral data reveal significant overprovision of medical services under fee-for-service and significant underprovision under capitation, although less than predicted when assuming profit maximization. Introducing mixed payment systems significantly reduces deviations from patient-optimal treatment. Although medical students tend to be more patient regarding, our results hold for both medical and non-medical students. Responses to incentive systems can be explained by a behavioral model capturing individual altruism. In particular, we find support that altruism plays a role in service provision and can partially mitigate agency problems, but altruism is heterogeneous in the population. Copyright © 2015 John Wiley & Sons, Ltd.

MACRA: A New Age for Physician Payments.

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 introduced a new system of physician payments in the United States. This legislation and the complex rules written to enact the law intend to force a shift away from volume-based payments and into so called value-based payments. Physicians and other clinicians will be graded via quality and cost metrics and payments will be adjusted based on performance. Robust use of certified electronic health records is required under MACRA. Physicians will follow one of two payment reform tracks known as the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) pathways. Although there are rheumatology and other specialty specific quality measures in the MIPS program, there are no rheumatology specific APMs to date. A thorough understating of MACRA is required for medical practices to survive the new era of payment reform.

(Re)disclosing physician financial interests: rebuilding trust or making unreasonable burdens on physicians?

Recent professional guidelines published by the General Medical Council instruct physicians in the UK to be honest and open in any financial agreements they have with their patients and third parties. These guidelines are in addition to a European policy addressing disclosure of physician financial interests in the industry. Similarly, In the US, a national open payments program as well as Federal regulations under the Affordable Care Act re-address the issue of disclosure of physician financial interests in America. These new professional and legal changes make us rethink the fiduciary duties of providers working under new organizational and financial schemes, specifically their clinical fidelity and their moral and professional obligations to act in the best interests of patients. The article describes the legal changes providing the background for such proposals and offers a prima facie ethical analysis of these evolving issues. It is argued that although disclosure of conflicting interest may increase trust it may not necessarily be beneficial to patients nor accord with their expectations and needs. Due to the extra burden associated with disclosure as well as its implications on the medical profession and the therapeutic relationship, it should be held that transparency of physician financial interest should not result in mandatory disclosure of such interest by physicians. It could lead, as some initiatives in Europe and the US already demonstrate, to voluntary or mandatory disclosure schemes carried out by the industry itself. Such schemes should be in addition to medical education and the address of the more general phenomenon of physician conflict of interest in ethical codes and ethical training of the parties involved.

Using structured incentives to increase value for money in an academic health sciences centre.

As healthcare continues to consume more and more of provincial government spending, there is a continuing pressure to improve efficiency and cut overall costs. In this increasingly constrained healthcare system, value for money is a growing focus of discussions around accountability and system sustainability; healthcare leaders are required to find ways of measuring, enforcing, and reporting on that value. In 2014, our organization began implementing an innovative system of structured incentives, linking distribution of Ministry of Health and Long-Term Care academic physician funding to quality and performance goals. Through a carefully planned process of benchmarking, stakeholder consultation, model improvement, and change management, we were able to move to a new value for money allocation model. The new model drives accountability by linking distribution of government payments to quality and performance outcomes. Initial results include increased stakeholder satisfaction as well as broader physician engagement in corporate and academic quality improvement initiatives.

A Look at MACRA: What to Expect in 2017.

The Medicare Access and Children's Health Insurance Program (CHIP) Reauthorization Act of 2015 fundamentally changes how physicians who care for Medicare patients will be paid. Although physicians won't see changes in their payments in 2017, they need to understand that their performance in 2017 will be the basis for the payments made to them starting in 2019. This article summarizes the two paths for determining future Medicare payments established by the law: the merit-based incentive payment system and advanced alternative payment models.

More than 800,000 docs get pass on MACRA compliance, for now.

CMS notified physicians that they won't have to comply with Merit-based Incentive Payment System reporting requirements in 2017.

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.