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The Effect of Explicit Financial Incentives on Physician Behavior
Brian S. Armour, PhD;
M. Melinda Pitts, PhD;
Ross Maclean, MD, MBA;
Charles Cangialose, PhD;
Mark Kishel, MD;
Hirohisa Imai, MD, PhD;
Jeff Etchason, MD
Arch Intern Med. 2001;161:1261-1266.
ABSTRACT
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Managed care organizations use explicit financial incentives to influence
physicians' use of resources. This has contributed to concerns regarding conflicts
of interest for physicians and adverse effects on the quality of patient care.
In light of recent publicized legislative and legal battles about this issue,
we reviewed the literature and analyzed studies that examine the effect of
these explicit financial incentives on the behavior of physicians. The method
used to undertake the literature review followed the approach set forth in
the Cochrane Collaboration handbook. Our literature review revealed a paucity
of data on the effect of explicit financial incentives. Based on this limited
evidence, explicit incentives that place individual physicians at financial
risk appear to be effective in reducing physician resource use. However, the
empirical evidence regarding the effectiveness of bonus payments on physician
resource use is mixed. Similarly, our review revealed mixed effects of the
influence of explicit financial incentives on the quality of patient care.
The effect of explicit financial incentives on physician behavior is complicated
by a lack of understanding of the incentive structure by the managed care
organization and the physician. The lack of a universally acceptable definition
of quality renders it important that future researchers identify the term
explicitly.
INTRODUCTION
A dynamic health care environment continues to affect and change the
way physicians practice medicine. Health services research studies have evaluated
only a fraction of the changes occurring throughout the health care system.
Reducing costs and unnecessary variation in clinical practice have become
goals of managed care organizations (MCOs) striving to deliver effective patient-centered
care and efficient population-level care. To that end, changing the clinical
practice behavior of physicians remains one of the great challenges facing
the health care sector.
The use of financial incentives is one means by which MCOs attempt to
influence physician behavior. There are numerous articles in the medical literature
examining the impact of financial incentives on physician behavior. This literature
has been reviewed in 4 recently published studies1-4
that examine the effect of implicit financial incentives (salary, capitation,
and fee-for-service) on physician resource use and the quality of care. This
article extends previous work by reviewing studies that examine the effect
of explicit financial incentives (bonuses and withholdings) on physician resource
use. The focus on explicit financial incentives has additional relevance in
light of a recently publicized Supreme Court case.5
At issue in the case is whether explicit financial incentives, in particular,
year-end bonuses linked to reductions in physician resource use, represent
a breach of fiduciary duty by the defendant health maintenance organization
(HMO) (CarleCare) under the Employment Retirement Income Security Act. The
court ruled that under the act, patients cannot sue HMOs for using financial
incentives to encourage physicians to contain costs.5
To reduce public concern surrounding MCO cost-containment measures,
several health care plans are using explicit financial incentives in an attempt
to improve the quality of patient care. Given the increasing prominence of
financial incentive programs, it is equally important to review the literature
and analyze studies that examine the effect of explicit financial incentives
on the quality of patient medical care.
BACKGROUND
Medical expenditures increased by approximately $1125 billion between
1960 and 1998, as shown in Table 1.
In real terms, this represents a 6-fold increase ($142.6 billion to $1106.1
billion). As a percentage of gross domestic product, medical expenditures
have increased from 5.1% to 13.5%. As a result, explaining the growth rate
in medical expenditures is a central issue in health economics. In addition,
reducing the growth rate in medical expenditures has become a key public policy
issue. Policy strategies designed to slow the growth rate in medical expenditures
have tended to focus on physicians, or the supply side of medical care.
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Table 1. Health Care Expenditures in the United States*
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Under fee-for-service reimbursement, in which physician compensation
is primarily a function of the supply of services and procedures, physicians
have an implicit financial incentive to increase the quantity of medical services,
provided the demand for medical care is inelastic and the price is greater
than the average cost of medical care. Furthermore, economic theory suggests
that the likelihood of providing such services increases when out-of-pocket
expenditures for patients are low, because most of the cost of the services
is passed on to a third party (insurers) for payment. The effects of different
reimbursement schemes on physician and consumer behavior are summarized in Table 2. The combination that produces
the lowest possible volume of medical services occurs when physicians are
paid by capitation or salary and bonus payments are high.
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Table 2. The Likelihood of a Primary Care Physician Providing a Large
Volume of Medical Services for Different Reimbursement and Consumer Copayment
Schemes*
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The use of fixed payment reimbursement schemes (salary and capitation)
is believed to be the most effective means of containing costs, by reducing
the incentive for physicians to increase the quantity of their services. The
percentage of the population affected by fixed payment reimbursement schemes
increased from 2.8% (6 million persons) in 1976 to 28.6% (76.6 million persons)
by 1998,10 with the number of managed care
plans increasing from 174 to 651 during this same period.
Under managed care arrangements in which physician compensation is based
on a capitated fee, physicians have a financial incentive to increase their
number of patients, as long as the fee is greater than the average cost of
caring for those patients. This, in turn, leads to the implicit incentive
to reduce the average cost of providing care by reducing the amount of time
spent with each patient and increasing the number of specialty referrals.
Because unnecessary specialty referrals increase the cost of care to the MCOs,
explicit financial incentives often are used to reduce such referrals.
This use of these explicit financial incentives may adversely affect
the quality of patient care. For example, bonuses and withholdings may provide
the physician with an explicit incentive to reduce all specialist referrals,
not just unnecessary ones. The Omnibus Budget Reconciliation Act of 198611 placed limitations on explicit incentive arrangements
between physicians and both hospitals and MCOs serving patients covered by
Medicare. Included in the act is a provision preventing explicit incentive
payment arrangements between MCOs and physicians. However, the law exempts
explicit financial arrangements between MCOs and physicians in which the gains
from improvements in efficiency (cost containment) outweigh small decreases
in the quality of care. As a result of this exception, patient protection
legislation has been enacted in several states to safeguard quality and to
alleviate public concern surrounding the influence of MCOs over their physicians.
In addition to the use of explicit financial incentives to contain costs,
several authors and health care plans share the view that the US health care
system would be better served if MCOs also used explicit financial incentives
to improve the quality of patient care.12-13
In response to these calls and to attempt to alleviate public concern surrounding
managed care cost-containment measures, many MCOs have used explicit financial
incentives to improve the quality of care. Therefore, the primary aim of this
article is to review evidence from the literature to help us understand whether
and how explicit financial incentives affect physician resource use and the
quality of medical care.
MATERIALS AND METHODS
The method used to undertake the literature review followed the approach
set forth in the Cochrane Collaboration handbook.14
The approach is described in an appendix that is available from the authors.
RESULTS
PHYSICIAN PERCEPTIONS OF EXPLICIT INCENTIVES
Grumbach et al13 analyzed survey responses
from 766 physicians to determine the effects of payments that MCOs use, in
addition to base compensation, to influence service use decisions and productivity.
Their responses revealed that physicians believe that HMOs use financial incentives
to influence productivity, service use (referrals and hospitalizations), the
quality of patient care, patient satisfaction, and prescription use. Physicians
reported that financial incentives in the form of bonus payments, on average,
amounted to 7% of their median net practice income, or approximately $10 500.
Fifty-eight percent of respondents who were eligible to receive incentive
payments reported that these payments were linked to individual and group
performance. Fifty-seven percent of respondents reported feeling pressure
to limit referrals, and, of these, 17% believed that this pressure negatively
impacted the quality of patient care. Respondents whose practices contained
a greater share of MCO enrollees indicated that they felt more financial pressure
to limit referrals and that this compromised the quality of patient care.
EMPIRICAL EVIDENCE
Whether physician perceptions are correct and explicit financial incentives
actually affect physician behavior is an empirical question that has been
the subject of relatively few studies. We have identified several such studies
from our review of the literature, the results of which are summarized herein.
In addition, we reviewed several observational studies that infer a connection.
First, we review studies that examine the relationship between explicit financial
incentives and resource use, followed by a review of studies that examine
the association between explicit financial incentives and the quality of medical
care.
RESOURCE USE
Hillman and colleagues15 used data from
a 1987 national survey of 595 HMO chief executive officers to determine whether
financial incentives affect physician use of services. Specifically, regression
analysis was used to examine the effect of financial incentives on resource
use (measured by hospitalization rates and primary care visits per enrollee)
and profitability (whether the HMO was fiscally viable). The types of financial
incentives included base compensation (salary, capitation, and fee-for-service),
bonuses, bonuses based on productivity, individual risk, specialist risk,
risk beyond specialist withholding, risk beyond hospital withholding, ancillary
risk (risk for the payment of outpatient medical tests), and the percentage
of HMO enrollees.
In addition, the regression model controlled for market area characteristics
and HMO descriptive variables. Market area characteristics included physician
demographic information and sample socioeconomic characteristics. Health maintenance
organization descriptive variables included type (independent practice association,
staff model, or group), size (number of enrollees), visits per enrollee, and
whether an HMO was affiliated with another organization.
The multiple regression results for this study suggest that explicit
financial incentives that place individuals at financial risk for deficits
in their referral funds decreased the number of primary care visits per enrollee
by approximately 11%. Placing physicians at risk for deficits in the hospital
fund beyond the hospital "withholding" resulted in a decrease in the number
of primary care visits per enrollee per year of approximately 8%. In addition,
physicians at risk for the costs of outpatient medical tests (ancillary risk)
substituted primary care visits for outpatient tests, which increased outpatient
visits per enrollee per year by 5%.
Hillman et al also found that ancillary payments, such as withholding
accounts and bonuses based on productivity, were not associated with a change
in physician resource use. The authors suggest that the absence of an association
might have been because of a contractual arrangement that delayed rewards
and, as a consequence, caused physicians to discount the value of the bonus
payments.
A limitation of the analysis by Hillman and colleagues is the possibility
of model specification error. Managed care organizations also typically use
nonfinancial incentives to influence physician resource use. To the extent
that nonfinancial incentives complement financial incentives, failing to include
them in the model will bias the results. Hillman and colleagues acknowledge
this limitation and suggest that future work should consider the effect of
both nonfinancial incentives and financial incentives on resource use.
To extend the work of Hillman et al, Debrock and Arnould11
analyzed data reports filed with the Illinois Department of Insurance for
35 MCOs operating in the state between 1985 and 1987. They sought to test
whether the awarding of bonuses to individual physicians is more effective
in reducing resource use than is a bonus system targeted at groups of physicians.
To examine the effect of compensation arrangements on physician behavior,
2 measures of service use were used: the total number of hospital admissions
per 1000 enrollees and the number of hospital visits per member. The independent
variables included in the regression model by Debrock and Arnould were grouped
under physician compensation arrangements, hospital incentives, managerial
control, HMO characteristics, patient characteristics, and market characteristics.
Regression analysis of the data indicated that explicit financial incentives
were effective in reducing physician resource use. Explicit financial incentives
directed at individual physicians reduced the number of hospital admissions
per 1000 enrollees by 16% and the mean number of visits per member from approximately
4 to approximately 2 per year. Debrock and Arnould11
concluded that explicit incentives should be directed at individual physicians
whose contracts include a withholding agreement. An individual physician who
bears all the risk has a greater incentive to use resources more parsimoniously
than do physicians who share their risk with a group.
QUALITY OF CARE
Hillman and colleagues16 analyzed data
on patients covered by Medicaid who enrolled in a Philadelphia, Pa, MCO between
1993 and 1995 to, in part, determine the effectiveness of explicit financial
incentives in improving physician delivery of breast, cervical, and colorectal
cancer screening. Fifty-two primary care practices were randomly assigned
either to an intervention or a control group. The intervention included semiannual
feedback to the physician with regard to adherence to cancer screening guidelines
and bonuses were paid to good performers. Medical records were sampled and
reviewed at the beginning of the study and semiannually for 18 months to rank
each practice.
Semiannual bonus payments ranging from 10% to 20% of capitation for
all women enrollees were paid to the top 6 practices with the highest cancer
screening rates. The mean bonus payment per audit was $775 per site. Analysis
of the baseline data revealed that there were no statistically significant
differences in cancer screening rates between the intervention and control
groups.
The authors concluded that the small incentive amount, lack of physician
awareness of the incentive program, and the type and length of the intervention
may explain the ineffectiveness of explicit financial incentives to improve
physician delivery of preventive services.
Kouides and colleagues17 analyzed Medicare
beneficiary claims data to examine the effect of performance-based incentives
on the influenza immunization rate in primary care physicians' offices in
Monroe County, New York. Fifty-four primary care practices participated in
the 1990 Medicare Influenza Vaccination demonstration project. Practices were
randomly assigned to an intervention or a control group. Physicians in both
groups agreed to track the immunization rates for their older patients ( 65
years) on a weekly basis. In addition to the standard $8 fee for influenza
immunization, physicians in the intervention group were paid an additional
$0.80 per shot if their practice attained an immunization rate of 70%. The
bonus payment doubled to $1.60 per shot if a practice attained an immunization
rate of 80%.
The mean immunization rate for the intervention practices, 68.6%, was
approximately 6 percentage points higher than the mean control group rate.
The median change in immunizations was 10.3% for the intervention group, compared
with 3.5% for the control group. Fifty-two percent (14/27) of practices in
the intervention group attained the 70% immunization target, compared with
44% (12/27) in the control group. Four practices attained the 80% target in
the intervention group, compared with 2 in the control group.
To further examine the relationship between influenza immunization rates
and explicit financial incentives, multiple regression analysis was conducted.
The dependent variable was defined as the change
in the percentage of patients immunized between the 1990 and 1991 influenza
seasons. The main independent variable of interest was a binary variable that
distinguished the intervention group practices from the control group practices.
Other variables included the percentage of elderly patients in each practice,
the number of physicians in each practice, the practice type (HMO or private),
the percentage of patients immunized in the baseline year, whether the practice
accepts persons covered by Medicaid, the number of preventive service reminders
each practice received, and the number of visits the study personnel made
to each practice. The regression results indicated that assignment to the
intervention group resulted in a 7% increase in the immunization rate among
older persons (P = .05). Finally, the authors reported
that 1433 more immunizations were observed than were expected in the intervention
group practices. They therefore concluded that small explicit incentives improve
immunization rates.
Hemenway18-19 reported that
in Northern Ireland in the early 1980s childhood immunization rates were only
about 12%. To improve immunization rates, the British government introduced
an incentive scheme for general practitioners who reached childhood immunization
targets. If 70% of the children on a general practitioner's patient list received
their immunizations on schedule, then the practitioner received an annual
bonus of approximately $1000. If he or she attained an immunization target
of 80%, the bonus increased to $3000. By 1991, 90% of general practitioners
had reached the lower target and 77% had reached the higher one.
One limitation of Hemenway's investigation is that the evidence presented
is observational. It is not possible to establish a connection between the
British government's use of explicit financial incentives and improvements
in childhood immunization rates in Northern Ireland, because there were no
control or comparison groups to help differentiate the effects of explicit
incentives from those of nonfinancial incentives, advertising, and other promotional
campaigns designed to improve immunizations.
To receive accreditation, many MCOs are participating in the National
Committee for Quality Assurance–Health Plan Employee Data and Information
Set performance measurement program. Hanchak20
reported that Aetna U.S. Healthcare Inc, Hartford, Conn, used several Health
Plan Employee Data and Information Set measures to design a performance-based
compensation scheme for obstetricians and gynecologists.
Each physician or physician group that contracts with Aetna receives
a bonus payment based on the "quality" of patient care. Quality is assessed
using 5 dimensions: (1) patient satisfaction, (2) appropriateness, (3) efficiency,
(4) effectiveness, and (5) managed care philosophy. Physicians receive points
based on their performance in each of these dimensions. A quality-based distribution
is then determined by multiplying the practitioners' score (points accumulated/total
possible points) by a predetermined bonus threshold amount. The quality-based
distribution is then allocated to the group. Hanchak20
reported that Aetna considered the performance-based compensation model to
be successful because cesarean section rates fell by 2%, length of hospital
stay was reduced by 25%, the use of biopsies increased by 85%, and precertification
approached 95% during the first 2 years of the program. There was a reported
improvement in all quality areas except patient satisfaction.
The model used by Aetna to gauge and subsequently reward physician performance
is important in that it illustrates possible tradeoffs that exist in improving
the quality of patient care. Patient satisfaction may not have improved because
the various areas that were used to generate the performance-based incentive
may be inversely related to patient satisfaction. The issue is whether Aetna's
performance measures are proxies for quality or cost containment. That is,
reductions in length of hospital stay and cesarean section rates will reduce
program costs. If these cost-containment measures result in lower patient
satisfaction scores, then it will be difficult for a physician to improve
in all these areas. However, by recognizing that some quality dimensions may
be inversely related, a health care plan may reduce this problem by assigning
weights to the dimensions used to reward performance. Indeed, Aetna weighs
cesarean section rates and adjusted lengths of hospital stay more than the
other quality dimensions. Hanchak20 did not
quantify the weights used to derive the quality score.
COMMENT
Our review of the literature suggests that explicit financial incentives
that place individual physicians at financial risk can be effective in influencing
physician resource use. However, the empirical evidence regarding the effectiveness
of bonus payments on physician resource use is mixed. Similarly, our review
disclosed mixed effects of the influence of explicit financial incentives
on the quality of patient medical care. Hillman et al16
found that bonus payments were ineffective in improving the quality of patient
care as defined by physician adherence to cancer screening guidelines. In
contrast, Kouides and colleagues17 found that
bonus payments improved the quality of patient care as defined by an increase
in the influenza immunization rate.
With one exception,20 the articles reviewed
separate the quality of patient medical care from resource use. Presumably,
this separation stems from the recognition of a potential quality vs resource
use tradeoff. Hanchak20 attempts to reduce
this tradeoff by including resource use as one of several dimensions of the
quality of the Aetna plan. Given that this definition of quality may reflect Aetna's preference for reducing costs, this may
be inconsistent with patient and physician preferences.
The results from existing observational studies are insufficient to
establish definitively a connection between bonus payments and the quality
of patient care in terms of improved preventive activities and process-of-care
measures. Furthermore, our review failed to find any empirical studies attempting
to link explicit financial incentives to health outcomes. Nevertheless, MCOs
are using explicit financial incentives to try to encourage physicians to
improve the quality of patient care. If MCOs intend to use explicit financial
incentives to influence physician behavior to improve the quality of patient
care, health care plan policy makers may wish to consider the following factors
when making contractual arrangements with their physicians:
1. Health maintenance organizations and other managed care plans may
contract with physicians directly, or they may contract with a middle tier
or physician group. The intermediary may blunt the effect of explicit financial
incentives. Therefore, it is important that HMOs and other MCOs: (a) determine the type of contractual arrangement between intermediary
organizations and physicians, (b) know whether the
explicit financial incentives are directed at individual physicians or a group,
and (c) ensure that physicians are aware of the extent
of their financial risk.
2. The differential impact of explicit incentives on physician behavior
in the setting of MCOs and traditional indemnity plans is not always clear,
as physicians often contract with several insurance plans and, in turn, are
compensated differently by the various organizations. As a consequence, an
organization that plans to use explicit financial incentives to improve quality
of care must consider the physicians' share of patients covered by the MCO.
If the number of patients covered by a health care plan represents a small
percentage of a physician's total patients, then it is unlikely that explicit
financial incentives unique to that plan will be effective in changing that
physician's behavior.
3. The magnitude of the risk represented by withholding incentives should
not be so great that it would cause physicians to behave in a way that might
be detrimental to the patient's health status.21
Although empirical evidence suggests that risk-bearing will affect physician
behavior,22 there is no empirical evidence
to indicate what the optimal level of risk-bearing should be.
4. Using explicit financial incentives to simultaneously reduce resource
use and improve quality of care may be problematic if cost-containment strategies
and quality are inversely related. The problem may be reduced by assigning
weights to the performance measures used to reward physicians. However, there
is no empirical evidence to indicate what these weights should be. Furthermore,
measures and definitions of health care quality need
to be explicitly defined so that it is clear to the provider exactly what
the financial incentive is meant to achieve.
CONCLUSIONS
Managed care organizations are using explicit financial incentives to
influence physician behavior, despite a paucity of empirical evidence as to
the effectiveness of these strategies. More research is needed to examine
the effect of performance-based incentives on the use of resources and the
quality of patient care. In particular, there needs to be research that examines
the impact of explicit financial incentives on the quality of care when those
incentives are implemented for the purpose of controlling resource use. To
carry out such research, it is important for investigators to be explicit
about the use of terms containing the word "quality." There is also a need
to determine how physicians respond to the magnitude of incentive amounts
at the individual and group levels.
Given the limited amount of research that has been applied to the use
of explicit financial incentives, along with the growing public and professional
distrust of the motives behind offering them, MCOs should undertake the use
of explicit financial incentives with great caution, if at all. Perhaps they
should be treated analogously to experimental therapies and only be used within
the context of rigorous evaluations to determine their impact on health care
quality and resource use.
AUTHOR INFORMATION
Accepted for publication August 30, 2000.
This study was funded by an educational grant from the Center for Healthcare
Improvement (Medical College of Georgia, Augusta), a collaborative venture
between the Medical College of Georgia and Blue Cross Blue Shield of Georgia,
Atlanta.
Corresponding author and reprints: Brian S. Armour, PhD, Kerr L.
White Institute for Health Services Research, 315 W Ponce de Leon Ave, Suite
321, Decatur, GA 30030 (e-mail: barmour{at}klwi.org).
From the Kerr L. White Institute for Health Services Research, Decatur,
GA (Drs Armour, Pitts, MacLean, Cangialose, Imai, and Etchason); Department
of Economics, Georgia State University, Atlanta (Dr Pitts); Department of
General Internal Medicine, Medical College of Georgia, Augusta (Drs MacLean
and Imai); Health Services Research Centre, Wellington, New Zealand (Dr Cangialose);
and Blue Cross Blue Shield of Georgia, Atlanta (Dr Kishel).
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