Effect of Payment Incentives on Cancer Screening in Ontario Primary Care

INTRODUCTION

Governments 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.^3–5

Reducing morbidity and mortality through cancer screening is an important component of primary care. Screening for cervical cancer⁶ and colorectal cancer⁷ is generally regarded as cost-effective. Screening for breast cancer via mammography is more controversial,^8–10 but is still widely recommended by clinical practice guidelines.^11,12 Nevertheless, a substantial proportion of individuals do not receive recommended cancer screening.^13–16 It is unclear whether pay for performance can shrink gaps in preventive care specifically^{17, 18} or primary care more generally.¹⁹

We evaluated a large-scale pay-for-performance scheme introduced in Ontario in 2006 and aimed at improving cancer screening in primary care.

METHODS

RESULTS

The characteristics of Ontarians eligible for and receiving screening in 2009–2010 are described in Table 2.

In 2009–2010, 84% (4,992) of eligible physicians billed at least 1 of the 3 cancer screening incentive codes and 22% (1,278) billed the highest payment category for all 3 cancer screening incentives.

During the study period, the age-adjusted screening rate increased from 55% to 57% for cervical cancer, 60% to 63% for breast cancer, and 20% to 51% for colorectal cancer (Figure 1). There was no significant step change in the screening rate for any of the 3 cancers in the year immediately after the incentives were introduced (Table 3). 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 2006–2007 and 2009–2010, a total of $28.3 million, $31.3 million, and $50.0 million in incentive payments was paid to physicians for cervical, breast, and colorectal cancer screening, respectively.

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Figure 1

Age- and sex-standardized cancer screening rates and annual incentive costs from 1990–2000 to 2009–2010.

For all 3 types of cancer screening, disparities in screening related to neighborhood income persisted over time. The ratios of the screening rates in the highest income quintile to those in the lowest quintile for cervical, breast, and colorectal cancer, respectively, were 1.28, 1.25, and 1.36 at the start of the study period and 1.33, 1.23, and 1.30 at the end. Individuals who were enrolled in a patient-centered medical home in 2009 had higher cancer-screening rates for all 3 types of cancer over the previous decade than those not enrolled. The ratios of the screening rates for individuals enrolled in a medical home in 2009 to the rates for those not enrolled, for cervical, breast, and colorectal cancer, respectively, were 1.46, 1.40, and 1.43 at the start of the study period and 1.96, 1.77, and 1.95 at the end.

DISCUSSION

Our findings demonstrate that the introduction of a province-wide, primary care pay-for-performance scheme for cervical, breast, and colorectal cancer screening was associated with little or no increase in cancer screening rates despite relatively large expenditure and very good uptake of incentives among primary care physicians. More, we found persistent disparities related to neighborhood income for all 3 types of cancer screening. Only physicians practicing in medical homes were eligible for the incentives, but individuals enrolled in a medical home were more likely to receive cancer screening than others even before introduction of the incentives.

Many factors influence the impact of financial incentives on quality of care,^{19, 26} but we hypothesize that the size and structure of Ontario’s incentive program played key roles in limiting its impact. The preventive care incentives were among the largest financial incentives introduced for primary care physicians in Ontario but constituted only about 3% of their gross income. Incentives were paid directly to physicians, not to the group practices or medical homes in which they worked. By contrast, in a pay-for-performance scheme for primary care physicians in the United Kingdom, incentive payments made up approximately 25% of physicians’ income, were paid to the group practice, and accelerated improvements in the quality of care for some chronic diseases.²⁷

Organizational and patient factors may also have influenced the impact of the incentives. Practices with electronic reminder systems have been shown to provide superior preventive care,²⁸ yet only 66% of primary care physicians in Ontario reported using electronic medical records and only 37% said they could easily generate a list of patients due for preventive care.²⁹ Cervical and breast cancer screening rates remained relatively stable over the last decade, as they have in the United States³⁰ and the United Kingdom,³¹ which may relate to some patients making an informed choice not to be screened. Other patients may need access to a female provider³² or education to address misconceptions before agreeing to be screened.³³ Small financial incentives directed to individual physicians are not likely to influence these factors.

We found that the largest improvement in screening associated with the pay-for-performance program was for colorectal cancer. This may relate to the lower baseline screening rate, the larger financial incentives, or a province-wide media campaign to promote colorectal cancer screening that launched in April 2008.

Income-related disparities in cancer screening persisted after the introduction of pay for performance. In contrast, the pay-for-performance scheme in the United Kingdom narrowed the gap in quality of care between practices serving low- and high-income populations.³⁴ This difference may be due to the smaller size of Ontario’s incentives and their limitation to physicians practicing in patient-centered medical homes, which in Ontario are less likely to serve low-income patients.²¹ Limiting the incentives to physicians practicing in medical homes also meant that the incentives rewarded physicians with higher baseline performance, a known pitfall of pay-for-performance schemes.³⁵

Overall, our findings are in keeping with published systematic reviews that have found limited evidence that provider incentives increase cancer screening rates.^17,18 There is, however, some evidence to support the use of other interventions, including patient or provider reminders, patient financial incentives, and organizational changes such as the adoption of standing orders for non-physician staff.^16,17,36 Population-based screening programs with jurisdiction-wide coverage and centrally organized recruitment and follow-up generally have higher screening rates than programs that rely solely on individual providers or organizations.¹⁶

Our study has 2 limitations that merit emphasis. First is our reliance on administrative data. We could not include fecal occult blood tests done in public hospitals and therefore likely underestimated screening rates. This limitation likely had minimal impact on our analysis of rates over time, though. Second, our observational study could not isolate the impact of the incentives from the impact of other interventions or definitively address causation. However, because we found little or no change in screening rates after the introduction of incentives, the issue of co-intervention is less relevant. In the case of colorectal cancer screening, the province-wide media campaign introduced during the same period as the physician incentives further limits inferences about the effects of either intervention on screening rates. There were no relevant changes in guidelines during the study period.

In summary, we found that a large scale pay-for-performance scheme for primary care physicians had limited impact on cancer screening rates 3 years after its widespread introduction despite substantial expenditures. Existing income-related disparities in screening rates persisted. Incentives were largely paid to physicians who had historically higher screening rates. Policy makers should consider other strategies for improving rates of cancer screening and reducing gaps in care.