A new study suggests that removing financial incentives for screening for cervical cancer, diabetic retinopathy, and hypertension and diabetes control reduces performance, including screening rates. The study was published online in May in the British Medical Journal (2010;340:c1898).
The lead investigator acknowledges, however, that the study is far from the last word on whether paying physicians to perform tests increases the fraction of the population that receives them.
“Our study adds more evidence to the incentives debate, but does not in any way conclusively show that incentives have a direct effect on screening rates,” said Helen Lester, MD, professor, NIHR School for Primary Care Research, Manchester, United Kingdom. “There are important caveats to this study, such as the difficulty of separating the impact of financial incentives from that of other regional efforts directed towards the same quality measures. So the most we can say is that there may be some change in doctor behavior once financial incentives are removed.”
Indeed, the Centers for Disease Control and Prevention’s Task Force on Community Preventive Services has found insufficient evidence to show financial incentives increase cancer screening (Am J Prev Med. 2008; 35[1S]:S21-S25), and that provider reminder and recall systems produce more significant increases in screening rates (Am J Prev Med. 2010;38[1]: 110-117).
Dr Lester and 6 other researchers from the United Kingdom and California examined the effects of adding or removing incentives for various screening tests and process measures. They focused on 35 outpatient facilities owned and operated by Kaiser Permanente Northern California that serve more than 2.5 million adults.
The facilities as a whole (rather than individual physicians) were given the incentives by Kaiser Permanente. The incentives were relatively large: in 2006, for example, the 35 facilities were awarded $42 million. The decision to add incentives was largely based on whether Kaiser officials believed the incentives were likely to significantly increase screening rates. The decision to remove incentives was based on whether the rates were projected to continue to increase without them because of the screening behavior or behaviors had become routine.
During the study period of 1999-2007, Kaiser Permanente first removed incentives paid to facilities for screening for diabetic retinopathy and cervical cancer, and then reinstated the cervical cancer screening incentives.
Dr Lester and her colleagues found that having incentives in place for diabetic retinopathy screening resulted in an increase from 84.9% of patients screened in 1999 to 88.1% screened in 2003. The incentives were then removed, and by 2007, the proportion had dropped to 80.5%.
Similarly, adding incentives for cervical cancer screening led to an increase of patients being screened from 77.4% to 78.0%. Removing the incentives was followed by a drop in rates to 74.3%, and adding the incentives again saw rates increase to 75.3%.
Value-Based Cancer Care asked Paul Shekelle, PhD, director, Southern California Evidence-Based Practice Center, RAND Corporation, and director, Quality Assessment and Quality Improvement Program, RAND Health, Los Angeles, for a comment.
He noted that the increases and decreases in screening rates were relatively small, and thus he “wouldn’t expect there to be a very great effect if the incentive were to be taken away in other centers or countries at other times.”
The study was conducted to determine what the effect might be of the planned removal of incentives for 8 clinical indicators in generalphysician offices across the United Kingdom in April 2011. Dr Shekelle said the results in the United Kingdom will depend on what substitutes are used for financial incentives, and whether these substitutes “are ingrained into the normal workflow” or not.
