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Doctors' Financial Incentives Have Little Effect on Diabetes Care Quality (August 23, 2012)

Recently, some health professionals have been receiving small financial bonuses intended to help them give their diabetic patients the best possible care. However, these incentives may not do much to change doctor behavior. A recent Canadian study suggests that “pay for performance” programs provide relatively little benefit. These findings are in line with other studies that have examined the effectiveness of these incentive programs.

What Is Pay for Performance?

A pay for performance system is one that gives money to doctors who achieve specific goals. These goals are set by a governing body or other group and are usually selected for their ability to reduce the risk of errors, decrease costs or increase patient health. Financial incentives may seem like a good way to encourage doctors to do a better job, but they tend to produce lackluster results in actual practice. Simply changing the doctor fee schedule seems to do relatively little. This doesn't mean that financial incentives can't help doctors and patients do better, however. Pay for performance methods can work when they're accompanied by systematic changes to help the doctors achieve their goals. This helps the entire medical system close the gap between what the data suggests should be common practice and what doctors and patients are actually doing.

Data on Pay for Performance

The government of Ontario began using a pay for performance method to provide incentives for its physicians starting in 2002. Each doctor received about $40 for each successful visit with a patient suffering from diabetes. In this case, success was determined by the ability to demonstrate that the patient was receiving a routine eye examinations blood cholesterol check and blood sugar glucose testing (and more accurately Hemoglobin A1c testing.) The Ontario study examined the medical bills of more than 700,000 patients who had diabetes to determine whether the program was working. Between the years of 2006 and 2008, however, only about 25 percent of patients had bills that indicated the doctor had met the requirements for the incentive payment. About 35 percent of all diabetic patients got the correct number of blood sugar tests during this period. About 60 percent got the right number of cholesterol tests. Over the course of the two year period, the rates of patients receiving all recommended tests did increase. This increase was gradual, however, and did not seem to be associated with doctors' financial incentives. In 2000, about 16 percent of patients received all the recommended routine exams. In 2008, this number increased to nearly 30 percent. This increase is similar to the annual rate of increase from before doctors became eligible for incentives.

Why Bonuses Don't Work

In many pay for performance programs, information is disseminated poorly and doctors aren't aware of their options. Many programs are also poorly funded and advertised, causing medical professionals to overlook them. In other cases, it's harder for doctors to earn the incentive, since they must fill out extra paperwork. The problem with pay for performance programs isn't limited to Canada, either. A program involving more than 250 U.S. hospitals had no measurable effect on the health of patients. The few programs that can show documented effectiveness tend to have a larger effect on physician income than simple bonuses. For instance, many primary care providers can actually benefit from completely redesigning their fee structure. When the doctor's office provides accessible, comprehensive care instead of using small incentives, patients fare much better. Of course, bonuses aren't the only way to ensure improvements. It's also important for patients to become their own advocates. People who suffer from diabetes should take the time to learn which blood tests are considered most appropriate for their situation. They should then take the time to insist on the full course of tests each year. Doctors who aren't willing to offer the tests of their own accord are often willing to provide them to patients who know what they need and who are willing to ask for it.