Bonuses for docs do little to improve diabetes care

NEW YORK Thu Apr 26, 2012 5:23pm EDT

A diabetic patient shows his insulin needle at a clinic in Los Angeles July 30, 2007. REUTERS/Lucy Nicholson

A diabetic patient shows his insulin needle at a clinic in Los Angeles July 30, 2007.

Credit: Reuters/Lucy Nicholson

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NEW YORK (Reuters Health) - Small financial incentives aimed at getting physicians to make sure their diabetic patients receive recommended routine exams may not lead to changes in doctors' behavior, according to a new study from Canada.

The findings echo much of what has been shown in other so-called pay-for-performance arrangements, said Meredith Rosenthal, a health policy researcher at the Harvard School of Public Health in Boston who wasn't involved in the study.

Those systems offer money to physicians who achieve certain goals that are known to improve patients' health, reduce errors or save money.

Rosenthal said financial incentives can affect medical care if they are accompanied by efforts to help doctors meet the goals. "I think there's a limited amount one can do just changing the fee structure around these things," she told Reuters Health.

Researchers and policymakers have been looking to pay-for-performance as one strategy to improve health outcomes.

"There's a big gap between what we're doing in practice and what the evidence tells us we should be doing," said Dr. Tara Kiran, the lead author of the study from St. Michael's Hospital and the University of Toronto.

"One way of potentially addressing this is, if we pay physicians to try and meet some quality targets, is that one way to close this knowledge-practice gap?"

Beginning in 2002, the government of Ontario offered to pay doctors $37 (Canadian -- about $38 U.S.) for each visit with a diabetes patient that demonstrated the patient was getting the recommended routine exams.

Those included eye exams, blood sugar monitoring and cholesterol measurements.

To see if this incentive program was working, Kiran and her colleagues examined the medical bills of more than 700,000 diabetic patients in Ontario.

The researchers found that between 2006 and 2008, only a quarter of patients had medical bills that included a charge for the incentive payment.

During that time, 37 percent of patients received the recommended number of blood sugar tests and 59 percent got the appropriate number of cholesterol tests, they reported in Diabetes Care.

"Rates of recommended testing increased gradually from 2006 to 2008, but it was not really associated with the incentive code," Kiran told Reuters Health.

Her results showed that the number of people who met the guidelines for all routine exams rose from 16 percent in 2000 to 27 percent in 2008, but the annual increase after the incentive became available was similar to what it was before doctors could earn the bonus.

Kiran said one possible explanation for the low uptake of the bonus is that doctors might not have been aware of it. Other incentives were introduced at the same time, and perhaps the diabetes incentive didn't get their attention -- or wasn't enough money, she suggested.

Earning the incentive also involved administrative work that some doctors might not have felt was worth the effort, researchers said. And not having electronic medical records or staff dedicated to managing chronic diseases could have made it too difficult to for doctors to meet the goals of the incentive.

Pay-for-performance programs have not shown much success in other settings, either.

For example, an incentive program involving 252 hospitals in the United States had no impact on patients' health (see Reuters report of March 28, 2012).

Dr. Michael Parchman, the director of the MacColl Center for Health Care Innovation at the Group Health Research Institute in Seattle, said there have been examples of pay-for-performance programs working, but they involved much larger impacts on doctors' incomes.

He said there's growing evidence that primary care practices benefit more from a complete redesign than from small, targeted incentives.

Shifting doctors' offices to a "medical home," which attempts to be more comprehensive and accessible in providing care for patients, seems to make a bigger difference, Parchman, who wasn't part of the new research team, told Reuters Health.

"We're nibbling around the edges with these kinds of small incentive payments when it comes to improving primary care delivery," he said. "We're not addressing the issue of: how do we redesign the way we provide primary care?"

SOURCE: bit.ly/HeFSn2 Diabetes Care, online March 28, 2012.

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