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Association Between Reimbursement Incentives and Physician Practice in OncologyA Systematic Review

Educational Objective
To review the association between reimbursement incentives and physician practice in oncology.
1 Credit CME
Key Points

Question  Do the financial incentives within oncology reimbursement affect physicians’ practice patterns?

Findings  In this systematic review of 18 studies that evaluated physicians’ response to reimbursement incentives across various clinical settings, most studies found evidence of an association between reimbursement incentives and delivery of cancer care. The ability to self-refer for radiation oncology services was associated with increased use of radiotherapy, and greater profitability of an anticancer drug was associated with increased use of that drug.

Meaning  How oncology care is reimbursed may affect clinical care delivery.


Importance  Significant controversy exists regarding whether physicians factor personal financial considerations into their clinical decision making. Within oncology, several reimbursement policies may incentivize physicians to increase health care use.

Objective  To evaluate whether the financial incentives presented by oncology reimbursement policies affect physician practice patterns.

Evidence Review  Studies evaluating an association between reimbursement incentives and changes in reimbursement policy on oncology care delivery were reviewed. Articles were identified systematically by searching PubMed/MEDLINE, Web of Science, Proquest Health Management, Econlit, and Business Source Premier. English-language articles focused on the US health care system that made empirical estimates of the association between a measurement of physician reimbursement/compensation and a measurement of delivery of cancer treatment services were included. The Risk of Bias in Non-Randomized Studies of Interventions tool was used to assess risk of bias. There were no date restrictions on the publications, and literature searches were finalized on February 14, 2018.

Findings  Eighteen studies were included. All were observational cohort studies, and most had a moderate risk of bias. Heterogeneity of reimbursement policies and outcomes precluded meta-analysis; therefore, a qualitative synthesis was performed. Most studies (15 of 18 [83%]) reported an association between reimbursement and care delivery consistent with physician responsiveness to financial incentives, although such an association was not identified in all studies. Findings consistently suggested that self-referral arrangements may increase use of radiotherapy and that profitability of systemic anticancer agents may affect physicians’ choice of drug. Findings were less conclusive as to whether profitability of systemic anticancer therapy affects the decision of whether to use any systemic therapy.

Conclusions and Relevance  To date, this study is the first systematic review of reimbursement policy and clinical care delivery in oncology. The findings suggest that some oncologists may, in certain circumstances, alter treatment recommendations based on personal revenue considerations. An implication of this finding is that value-based reimbursement policies may be a useful tool to better align physician incentives with patient need and increase the value of oncology care.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships. If applicable, all relevant financial relationships have been mitigated.

Article Information

Accepted for Publication: September 24, 2018.

Corresponding Author: Aaron P. Mitchell, MD, MPH, Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, 485 Lexington Ave, Second Floor, office 2093, New York, NY 10017 (

Published Online: January 3, 2019. doi:10.1001/jamaoncol.2018.6196

Author Contributions: Dr Mitchell had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Mitchell, Richardson, Wheeler, Goldstein.

Acquisition, analysis, or interpretation of data: Mitchell, Rotter, Patel, Richardson, Basch, Goldstein.

Drafting of the manuscript: Mitchell, Rotter, Richardson.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Mitchell, Patel.

Administrative, technical, or material support: Rotter, Patel.

Supervision: Mitchell, Wheeler, Goldstein.

Conflict of Interest Disclosures: Dr Wheeler has received research grant funding from Pfizer unrelated to this work. No other disclosures reported.

Funding/Support: This research was partially supported by a National Research Service Award Post-Doctoral Traineeship from the Agency for Healthcare Research and Quality (grant 5T32 HS000032-28) (Dr Mitchell and Ms Patel) and by a Conquer Cancer Foundation Young Investigator Award (Dr Mitchell).

Role of the Funder/Sponsor: The funding organizations had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Additional Contributions: Daniel Jonas, MD, MPH, and Sarah Wright, MLS (University of North Carolina at Chapel Hill), assisted with project design and construction of database search terms. There was no financial compensation outside of salary.

Additional Information: This review was registered in the PROSPERO International Prospective Register of Systematic Reviews (CRD42018085892) on February 15, 2018.

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