Financial Incentives for Quality in Breast Cancer Care

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.

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.

CONCLUSIONS

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.

To read this article in its entirety, including Methods, Results, and Discussion, visit the MDNGLive sister site for The American Journal of Managed Care.

REFERENCES

1. Kerr EA, Mittman BS, Hays RD.

? JAMA. 1996;276(15):1236-1239.

2. Kerr EA, Hays RD, Mittman BS, et al.

. JAMA. 1997;278(4):308-312.

3. Hargraves JL, Palmer RH, Orav EJ, et al.

. 1996;34(9 suppl):SS67-SS76.

4. Stoddard JJ, Reed M, Hadley J.

. J Ambul Care Manage. 2003;26(1):39-50.

5. Conrad DA, Sales A, Liang SY, et al.

. Health Serv Res. 2002;37(4):885-906.

6. Greenfield S, Nelson EC, Zubkoff M, et al.

. JAMA. 1992;267(12):1624-1630.

7. Mandelblatt JS, Berg C, Merpol NJ, et al.

. Med Care. 2001;39(3):228-242.

8. Bennett CL, Bishop MR, Tallman MS, Somerfield MR, Feinglass J, Smith TJ; Health Services Research Committee of the American Society of Clinical Oncology.

: results from the 1997 American Society of Clinical Oncology Survey. Ann Oncol. 1999;10(11):1355-1359.

9. Gosden T, Forland F, Kristiansen IS, et al.

. J Health Serv Res Policy. 2001;6(1):44-55.

10. Shortell SM, Zazzali JL, Burns LR, et al.

. Med Care. 2001;39(7 suppl 1):I62-I78.

11. Keating NL, Landon BE, Ayanian JZ, Borbas C, Guadagnoli E.

. J Gen Intern Med. 2004;19(5 pt 1):410-418.

12. Hillman AL, Ripley K, Goldfarb N, Weiner J, Nuamah I, Lusk E.

. Pediatrics. 1999;104(4):931-935.

13. Kouides RW, Bennett NM, Lewis B, Cappuccio JD, Barker WH, LaForce FM; Primary-Care Physicians of Monroe County.

. Am J Prev Med. 1998;104(4):931-935.

14. Roski J, Jeddeloh R, An L, et al.

. Prev Med. 2003;36(3):291-299.

15. Malin JL, Schuster M, Kahn KL, Brook RH.

? J Clin Oncol. 2002;20(21):4381-4393.

16. Malin JL, Schneider E, Epstein A, et al.

: how can we improve the quality of cancer care in the United States? J Clin Oncol. 2006;24(4):626-634.

17. Kahn KL, Schneider E, Malin JL, Adams JL, Epstein AM.

: predicting long-term adherence to tamoxifen use. Med Care. 2007;45(5):431-439.

18. Greenberg CC, Schneider EC, Lipsitz SR, et al.

? J Am Coll Surg. 2008;206(4):605-615.

19. Yoon J, Malin J, Tisnado DM, et al.

: is it influenced by patient characteristics? Breast Cancer Res Treat. 2008;108(1):69-77.

20. Town R, Wholey DR, Kralewski J, Dowd B. Assessing the influence of incentives on physicians and medical groups. Med Care Res Rev. 2004;61(3 suppl):80S-118S.

21. Tisnado DM, Malin JL, Ganz PA, et al. The structural landscape of the health care system for breast cancer care in Los Angeles County: results from a physician survey. Breast J. In press.

Quality assurance in capitated physician groups: where is the emphasisPrimary care physicians’ satisfaction with quality of care in California capitated medical groupsPractice characteristics and performance of primary care practitioners. Med CareFinancial incentives and physicians’ perceptions of conflict of interest and ability to arrange medically necessary servicesThe impact of financial incentives on physician productivity in medical groupsVariations in resource utilization among medical specialties and systems of care: results from the Medical Outcomes StudyMeasuring and predicting surgeons’ practice style for breast cancer treatment in older womenThe association between physician reimbursement in the US and use of hematopoietic colony stimulating factors as adjunct therapy for older patients with acute myeloid leukemiaImpact of payment method on behaviour of primary care physicians: a systematic reviewImplementing evidencebased medicine: the role of market pressures, compensation incentives, and culture in physician organizationsPractice, clinical management, and financial arrangements of practicing generalistsThe use of physician financial incentives and feedback to improve pediatric preventive care in Medicaid managed carePerformance-based physician reimbursement and influenza immunization rates in the elderlyThe impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelinesQuality of breast cancer care: what do we knowResults of the National Initiative for Cancer Care QualityPatient centered experiences in breast cancerDo variations in provider discussions explain socioeconomic disparities in postmastectomy breast reconstructionSymptom management after breast cancer treatment