Financial Incentives for Quality in Breast Cancer Care

Objectives

: To examine the use of financial incentives related to performance on quality measures reported by oncologists and surgeons associated with a population-based cohort of patients with breast cancer in Los Angeles County, California, and to explore the physician and practice characteristics associated with the use of these incentives among breast cancer care providers.

Study Design

: Cross-sectional observational study.

Methods

: Physician self-reported financial arrangements from a survey of 348 medical oncologists, radiation oncologists, and surgeons caring for patients with breast cancer in Los Angeles County (response rate, 76%). Physicians were asked whether they were subject to financial incentives for quality (ie, patient satisfaction surveys and adherence to practice guidelines). We examined the prevalence and correlates of incentives and performed multivariate logistic regression analyses to assess predictors of incentives, controlling for other covariates.

Results

: Twenty percent of respondents reported incentives based on patient satisfaction, and 15% reported incentives based on guideline adherence. The use of incentives for quality in this cohort of oncologists and surgeons was modest and was primarily associated with staff- or group-model health maintenance organization (HMO) settings. In other settings, important predictors were partial physician ownership interest, large practice size, and capitation.

Conclusions

: Most cancer care providers in Los Angeles County outside of staff- or group-model HMOs are not subject to explicit financial incentives based on quality-of-care measures. Those who are, seem more likely to be associated with large practice settings. New approaches are needed to direct financial incentives for quality toward specialists outside of staff- or group-model HMOs if pay-for-performance programs are to succeed in influencing care.

(Am J Manag Care. 2008;14(7):457-466)

The use of financial incentives based on quality-of-care measures among surgeons and medical and radiation oncologists caring for patients with breast cancer in Los Angeles County, California, was modest, with 20% reporting incentives based on patient satisfaction and 15% reporting incentives based on guideline adherence, similar to rates among primary care physicians a decade ago.

Most cancer care providers outside of staff- or group-model health maintenance organizations (HMOs) were not subject to financial incentives based on quality-ofcare measures.

New approaches to direct financial incentives for quality toward specialists outside of staff- or group-model HMOs are needed if pay-for-performance programs are to succeed.

Healthcare quality is of concern nationally, and healthcare structural arrangements have been evolving rapidly to respond to increasing financial pressures and demands to enhance quality. These changes have been shown to affect primary care delivery,^1-4 yet little is known about how these new organizational and financial arrangements affect the delivery of specialty care, particularly in the context of cancer.

It has long been recognized that financial incentives can have a powerful influence on physician and patient behavior. Associations have been found between implicit financial incentives (ie, provider compensation type) and productivity,⁵ resource use,⁶ propensity to use particular treatment options such as breast-conserving surgery7 and growth factors,⁸ continuity, compliance, patient satisfaction,⁹ and the use of evidence-based medicine practices.¹⁰ Explicit incentives for quality (ie, direct financial incentives tied to performance on quality measures or “pay for performance”) have been viewed as a mechanism to stimulate improvements in healthcare quality and patient outcomes by better aligning financial incentives with the delivery of higher-quality care. Although the effect of explicit financial incentives on primary care physicians has been the subject of several studies,^4,11-14 understanding of these financial arrangements among specialists remains limited. Even less is known about the financial incentives used among specialists who provide cancer care in today’s managed care–penetrated environment.

Breast cancer serves as an excellent condition to use as a model for the study of structural characteristics and how they influence quality of care in general and cancer care more specifically. Breast cancer is a complex expensive disease with multiple treatments delivered by multiple providers over time, making patients vulnerable to problems with quality such as poor continuity and coordination of care.

Practice guidelines for breast cancer care issued by the National Comprehensive Cancer Network have been in place since the 1990s. However, a 2002 review¹⁵ of the patterns-of-care literature found notable variations in axillary lymph node dissection, hormone receptor status documentation, radiation therapy after breast-conserving surgery, and the use of tamoxifen citrate. The National Initiative for Cancer Care Quality,¹⁶ an in-depth study of quality of care for patients with breast or colorectal cancer in 5 states across the United States from 1998 to 2002, revealed substantial opportunities for improvement. Adherence was less than 85% for half of the quality measures, and substantial variation was found across metropolitan areas. Significant proportions of eligible patients did not complete an indicated course of tamoxifen¹⁷ and had no documented discussion about postmastectomy reconstruction.¹⁸ In a population-based study¹⁹ conducted in 2000 in Los Angeles County, California, 60% of black women, 55% of Spanish-speaking Hispanic women, and 34% of white women did not receive desired help for symptoms. Concerns about financial incentives motivating overuse of certain cancer treatments such as growth factors have also been expressed.⁸

Based on theoretical grounds²⁰ and evidence from previous interventions,^13,14 it is reasonable to expect that financial incentives for quality have the potential to influence physician behavior, aligning financial incentives with desired outcomes. At the time that we conducted the present study, we were unaware of any specific pay-for-performance systems in oncology, but with the substantial energy and enthusiasm mounting behind pay for performance as a way to motivate and reinforce quality in general medicine, as well as the rising concerns regarding quality in oncology, we set out to assess the state of uptake among oncologists and surgeons treating patients with breast cancer.

We developed and conducted a physician survey to describe the structure of breast cancer care in Los Angeles County²¹ and to evaluate the effect of structure on the quality of care that patients with breast cancer receive.¹⁹ In this article, we present findings regarding the prevalence and types of financial incentives tied to performance on quality measures reported by oncologists and surgeons associated with a population-based cohort of patients with breast cancer in Los Angeles County. To assess the determinants of financial incentives tied to performance on quality measures, we explore the physician and practice characteristics associated with the use of these incentives among breast cancer care providers. Based on the literature and cognitive interviews conducted to inform the development of the survey, we hypothesized that explicit incentives for quality, although available and potentially useful for motivating and reinforcing cancer quality assessment and improvement efforts, would be rarely used except for large group-model health maintenance organizations (HMOs) or large multispecialty medical group practices.

METHODSWe conducted a cross-sectional study of the structure and organization of care associated with the physicians identified among a population-based sample of women with incident breast cancer participating in the Los Angeles Women’s Health Study, which included a population-based sample of women 50 years and older identified as having a new diagnosis of breast cancer in Los Angeles County in 2000 by the Los Angeles County Cancer Surveillance Program Rapid Case Ascertainment system. A computerassisted telephone interview (CATI) was administered to 1224 women who agreed to participate. The detailed CATI queried women about healthcare providers who fulfilled various roles in their care, including delivering, recommending, or discussing the possible use of breast cancer treatments. We targeted all Los Angeles County medical oncologists, radiation oncologists, and surgeons reported by their patients in the CATI.

We developed items to query physicians about financial reimbursement arrangement and incentives. These were based on the literature^5,9,10,22-27 and on cognitive interviews with cancer care specialists.

Patient Case Mix

Physicians were asked to report the proportions of patients in their main practice setting who were primarily covered by each of the following: Medicare fee for service (FFS), Medicare managed care, MediCal FFS, MediCal managed care, private traditional FFS health insurance, private managed care health insurance, other health coverage, and no coverage (uninsured).

Physician Compensation MethodWe asked physicians to indicate the proportions of clinical compensation that are paid to them in the following ways: salary that is fixed for the year or contract period; salary that may vary during the year or contract period according to factors such as productivity, performance review, and net income of the practice, FFS or discounted FFS, capitated reimbursements, and other.

Financial Incentives for QualityPhysicians were asked whether in the previous 12 months their pay was affected in any way as a result of scoring well on the following: (1) patient satisfaction surveys or (2) other specific measures of quality of care such as adherence to practice guidelines or protocols.

Practice SettingWe accounted for the importance in Southern California of network-model managed care involvement. To do so, we derived new practice setting categories by dividing single-specialty medical groups, multispecialty medical groups, and solo practices into high and low managed care, using as a cut point the median reported percentage (36%) of network-model managed care patients.

Study Design

Table 1

gives results describing characteristics of the physician sample by specialty type and overall. Overall, 20% of respondents reported being subject to incentives for quality based on the results of patient satisfaction surveys and 15% based on the results of other quality measures such as adherence to practice guidelines. Twenty-two percent reported being subject to either, and 13% reported being subject to both types of incentives. These rates did not differ significantly by specialty type.

Table 3

gives the results of multivariate analyses. In the multivariate analyses, 2 sets of logistic regression analyses were performed for each of the 3 dependent variables, namely, incentives based on the results of (1) patient satisfaction surveys, (2) other quality measures such as adherence to practice guidelines, and (3) both incentive types. We predicted the use of financial incentives for quality as a function of ownership interest, practice setting type, practice size, FFS reimbursement type, and acceptance of capitation among all physicians surveyed.

In logistic regression analyses predicting incentives based on patient satisfaction (Table 3), group-model HMO practice type was far more likely to be associated with reported use of incentives for quality compared with solo practice type (OR, 33.20; P <.001), controlling for ownership interest, practice size, and reimbursement type. Other significant predictors were partial ownership interest compared with full ownership (P = .04) and large practice size compared with small practice size (P = .005). Physician sex and specialty type were not significantly associated with the use of incentives for quality and were excluded from final models.

Model 1 in Table 3, including all physicians, illustrates that the use of incentives based on patient satisfaction was overwhelmingly associated with staff- or group-model HMO practice setting type. Model 2 (n = 284) restricted the analysis to physicians not associated with group-model HMOs using the same covariates. In model 2, significant predictors of incentives based on patient satisfaction were partial ownership interest versus full ownership (OR, 4.94; P = .002) and any reimbursement in the form of capitation versus none (OR, 3.26; P = .01).

Results of the 2 models predicting incentives based on other quality measures such as adherence to quality measures demonstrate that significant predictors of incentives based on quality measures other than patient satisfaction were staff- or group-model HMO practice setting type (OR, 8.58; P = .04) and large practice size (OR, 4.41; P = .006) (Table 3). Reimbursement predominantly in the form of FFS was negatively associated with the use of such incentives (OR, 0.23; P = .03). Ownership interest was not signnificant. In the model excluding staff- or group-model HMO physicians, only large practice size was a significant predictor (OR, 4.78; P = .04).

Table 3 also gives results of analyses that specify as dependent variables the use of financial incentives based on both types of quality measures. The results of model 1 were consistent with the results in which the dependent variable was incentives based on quality measures other than patient satisfaction, except that ownership interest was not significant. Excluding staff- or group-model HMO physicians, no independent variables were significant in model 2.

DISCUSSION

Most cancer care providers in Los Angeles County outside of staff- or group-model HMOs are not subject to financial incentives based on quality-of-care measures, and those who are seem more likely to be associated with large practice settings. New approaches will be needed to direct financial incentives for quality toward specialists outside of staff- or group-model HMOs if pay-for-performance programs are to succeed in improving quality. However, further research is needed to determine whether the use of financial incentives can indeed influence cancer care and outcomes and what, if any, associations exist between implicit financial incentives (eg, reimbursement based on FFS, capitation, or salary), explicit financial incentives linked to performance on quality measures, and actual outcomes of patients with cancer.

Author Affiliations: Department of Medicine (DMT, KLK) and Jonsson Comprehensive Cancer Center (DER-A, PAG), University of California, Los Angeles; Amgen Inc, Thousand Oaks, CA (JLM); and RAND, Santa Monica, CA (JLA).

Funding Source: This work was supported by a grant from the California Breast Cancer Research Program (#7PB-0126). Dr Tisnado received additional grant support from a Department of Defense Breast Cancer Research Postdoctoral Program (#DAMS17-03-1-0328) and the UCLA Center for Health Improvement of Minority Elderly/Resource Centers for Minority Aging Research (NIH/NIA #P30AG021684). Dr Rose-Ash received grant support from a UCLA Cancer Education and Career Development National Cancer Institute (#R25 CA 087949).

Author Disclosure: The authors (DMT, DER-A, JLM, JAL, PAG, KLK) report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article. This study was presented in part at the annual sessions of the 24th AcademyHealth Research Meeting; June 3-5, 2007; Orlando, FL; and at the California Breast Cancer Research Program; September 7-9, 2007; Los Angeles, CA.

Authorship Information: Concept and design (DMT, DER-A, JLM, PAG); acquisition of data (DMT, DER-A); analysis and interpretation of data (DMT, DER-A, JLM, PAG); drafting of the manuscript (DMT); critical revision of the manuscript for important intellectual content (DMT, DER-A, JLM, PAG); statistical analysis (DMT, DER-A); provision of study materials or patients (DMT); obtaining funding (DMT); and administrative, technical, or logistic support (DMT).

Address correspondence to: Diana M. Tisnado, PhD, Department of Medicine, University of California, Los Angeles, 911 Broxton Plz, Los Angeles, CA 90095-1736. E-mail: dtisnado@mednet.ucla.edu.

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