Article Figures & Data
Figures
- Figure 1
Age- and sex-standardized cancer screening rates and annual incentive costs from 1990–2000 to 2009–2010.
Tables
- Table 1
Description of Financial Incentives for Cancer Screening Introduced for Primary Care Physicians in Ontario in 2006–2007
Cancer Screening Patients Included in Incentive Calculationa Patients Excluded From Incentive Calculation Fee Codes Self-reported Target Achieved, % Financial Value, $ Cervical Enrolled women aged 35 to 69 yb who had received a Papanicolaou test in the previous 30 mo Women who had undergone hysterectomy Q105 60 220 Q106 65 440 Q107 70 660 Q108 75 1,320 Q109 80 2,200 Breast Enrolled women aged 50 to 69 yb who had received a mammogram in the previous 30 mo Women who had had a mastetomy or were being treated for breast cancer Q110 55 220 Q111 60 440 Q112 65 770 Q113 70 1,320 Q114 75 2,200 Colorectal Enrolled adults aged 50 to 74 yb who had received a fecal occult blood test in the previous 30 mo Adults who had colon cancer, IBD, or malignant bowel disease or had undergone colonoscopy in the previous 10 y Q118 15 220 Q119 20 440 Q120 40 1,100 Q121 50 2,200 Q122c 60 3,300 Q123c 70 4,000 - Table 2
Characteristics of Ontarians Eligible for and Receiving Cervical, Breast, and Colorectal Cancer Screening in the 30 Months Before March 31, 2010
Cervical Cancer Breast Cancer Colorectal Cancer Characteristic Eligible for Screening No. Receiving Screening % Eligible for Screening No. Receiving Screening % Eligible for Screening No. Receiving Screening % All 3,056,337 57.0 1,600,645 62.3 3,713,963 50.9 Sex Female 3,056,337 57.0 1,600,645 62.3 1,885,988 53.8 Male 1,827,975 47.8 Age, y 35–39 513,044 60.6 40–44 527,937 59.5 45–49 554,117 59.9 50–54 479,207 59.1 534,558 56.6 1,088,421 39.7 55–59 405,701 55.3 451,136 63.9 913,044 50.3 60–64 355,784 50.5 384,723 66.7 781,940 56.1 65–69 220,547 44.6 230,228 67.2 568,175 59.9 70–74 362,383 60.4 Income quintile Missing 45,676 20.0 18,552 25.8 45,212 25.4 Q1 (lowest) 554,378 47.9 283,930 55.1 664,969 43.5 Q2 579,454 54.0 307,993 60.7 714,839 48.5 Q3 594,351 58.5 309,868 63.7 716,872 51.2 Q4 635,142 62.1 329,077 66.2 761,444 54.05 Q5 (highest) 647,336 63.8 351,225 67.9 810,627 57.2 Resource Utilization Band 0 (no utilization) 451,310 3.5 183,462 4.8 487,843 5.6 1 113,116 54.0 43,829 47.9 103,253 34.7 2 400,656 58.2 181,700 56.2 431,944 42.7 3 1,575,521 68.6 898,747 71.0 1,960,256 59.6 4 412,256 71.6 213,565 73.5 498,735 65.7 5 (high utilization) 103,436 55.0 79,333 66.0 231,898 62.5 Medical home enrollment Enrolled 2,131,774 66.8 1,160,502 71.1 2,626,302 59.5 Other 924,563 34.4 440,143 40.1 1,087,661 36.0 Comorbidities Diabetes 263,512 53.5 212,612 66.2 609,372 57.2 Hypertension 662,545 57.5 571,053 69.9 1,470,212 59.5 CHF 19,661 38.8 19,521 57.2 78,220 54.6 AMI 12,656 40.2 12,461 56.6 79,900 51.9 Asthma 349,384 62.9 198,934 68.6 376,494 59.3 COPD 174,932 52.5 157,279 64.9 405,258 56.9 Any mental health* 549,347 67.8 300,793 70.2 587,783 59.8 Psychotic 43,219 57.7 25,172 61.5 51,048 51.3 Nonpsychotic 499,888 68.3 273,972 70.6 525,024 60.7 Substance use/other 64,387 66.5 31,650 66.4 71,826 54.0 -
CHF = congestive heart failure; AMI = acute myocardial infarction; COPD = chronic obstructive pulmonary disease.1
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↵* Categories under this heading are nonexclusive.
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Notes: Eligibility is defined per preventive care incentive parameters. Cervical cancer screening: women aged 35 to 69 years as of March 31, 2010, who have had a Papanicolaou test in the last 30 months, excluding women who have had a hysterectomy. Breast cancer screening: women aged 50 to 69 years as of March 31, 2010, who have had a mammogram in the last 30 months, excluding women who have had a mastectomy or are being treated for breast cancer. Colorectal cancer screening: adults aged 50 to 74 years as of March 31, 2010, who have had a fecal occult blood test in the last 30 months or a colonoscopy in the past 10 years, excluding adults with known colon cancer.
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- Table 3
Segmented Regression Model Parameters Showing the Year-to-Year Trend in Cancer Screening Rates Before and After Introduction of Ontario’s Preventive Care Incentives In 2006–2007
Type of Cancer Screening Intercept (β0) % (95% CI) Baseline Trend Before Incentives (β1) % (95% CI) Step Change After Introduction of Incentives (β2) % (95% CI) Trend Change After Introduction of Incentives (β3) % (95% CI) Trend After Introduction of Incentives ( β1+ β3) % (95% CI) Cervical 53.9 (52.5 to 55.3) 0.26 (−0.054 to 0.57) 1.5 (−0.80 to 3.8) −0.21 (−1.0 to 0.59) 0.045 (−0.70 to 0.79) Breast 60.9 (59.7 to 62.0) −0.24 (−0.49 to 0.015) 1.6 (−0.25 to 3.5) 0.72 (0.080 to 1.4) 0.49 (−0.10 to 1.1) Colorectal 17.2 (15.0 to 19.5) 3.0 (2.3 to 3.7) 0.95 (−2.2 to 4.1) 1.7 (0.55 to 2.9) 4.7 (3.7 to 5.7) -
Note: The segmented linear regression models are Yt= β0 +β1*timet +β2*interventiont +β3*time after interventiont +et, where Yt stands for observed series and et represents an error term. These regression models allow for a linear trend before intervention, a step change after intervention, and a linear trend change after intervention.
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Supplemental Table
Supplemental Table 1. Other Fee Code Codes Introduced Along With Preventive Care Incentives and Included in Calculation of Incentive Costs
Files in this Data Supplement:
- Supplemental data: Table - PDF file
In Brief
Effect of payment incentives on cancer screening in Ontario primary care
Tara Kiran , and colleagues
Background Pay for performance, in which clinicians are rewarded for meeting targets for delivering health care services, has been seen by many as a promising approach to reducing health system cost and improving quality. This study evaluates a large-scale pay for performance program, introduced in Ontario in 2006, aimed at improving primary care screening for cervical, breast, and colorectal cancers.
What This Study Found Despite substantial expenditures, a large-scale pay-for-performance plan had limited impact on cancer screening rates three years after its introduction. The year after incentives were introduced, there was no significant step change in screening rates for the three cancers. Yet, between 2006-2007 and 2009-2010, a total of $28.3 million, $31.3 million, and $50 million in incentive payments were paid to physicians for cervical, breast, and colorectal cancer screening, respectively. For all three types of cancer screening, disparities in screening related to neighborhood income persisted over time. The size and structure of Ontario?s incentive program may have played key roles in limiting its impact; although preventive care incentives were among the largest financial incentives introduced for primary care physicians in Ontario, they constituted only about 3% of their gross income. By contrast, in a pay-for-performance plan for primary care physicians in the United Kingdom, which accelerated improvements in the quality of care for some chronic diseases, incentive payments made up approximately 25% of physicians' income.
Implications
- These findings are in keeping with other published studies finding limited evidence for the effectiveness of pay-for-performance plans in improving cancer screening. As a result, the authors conclude policy makers should consider other strategies for improving rates of cancer screening and reducing gaps in care.
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