Association Between Reimbursement Incentives and Physician Practice in Oncology | Oncology | JN Learning | AMA Ed Hub [Skip to Content]
[Skip to Content Landing]

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.

Abstract

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.

Sign in to take quiz and track your certificates

Buy This Activity

JN Learning™ is the home for CME and MOC from the JAMA Network. Search by specialty or US state and earn AMA PRA Category 1 CME Credit™ from articles, audio, Clinical Challenges and more. Learn more about CME/MOC

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 (mitchea2@mskcc.org).

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.

References
1.
Shah  BR, Cowper  PA, O’Brien  SM,  et al.  Association between physician billing and cardiac stress testing patterns following coronary revascularization.  JAMA. 2011;306(18):1993-2000. doi:10.1001/jama.2011.1604PubMedGoogle ScholarCrossref
2.
Mitchell  JM.  Urologists’ self-referral for pathology of biopsy specimens linked to increased use and lower prostate cancer detection.  Health Aff (Millwood). 2012;31(4):741-749. doi:10.1377/hlthaff.2011.1372PubMedGoogle ScholarCrossref
3.
Gruber  J, Owings  M.  Physician financial incentives and cesarean section delivery.  Rand J Econ. 1996;27(1):99-123. doi:10.2307/2555794PubMedGoogle ScholarCrossref
4.
Clemens  J, Gottlieb  JD.  Do physicians’ financial incentives affect medical treatment and patient health?  Am Econ Rev. 2014;104(4):1320-1349. doi:10.1257/aer.104.4.1320PubMedGoogle ScholarCrossref
5.
Nguyen  LL, Smith  AD, Scully  RE,  et al.  Provider-induced demand in the treatment of carotid artery stenosis: variation in treatment decisions between private sector fee-for-service vs salary-based military physicians.  JAMA Surg. 2017;152(6):565-572. doi:10.1001/jamasurg.2017.0077PubMedGoogle ScholarCrossref
6.
Hollingsworth  JM, Ye  Z, Strope  SA, Krein  SL, Hollenbeck  AT, Hollenbeck  BK.  Physician-ownership of ambulatory surgery centers linked to higher volume of surgeries.  Health Aff (Millwood). 2010;29(4):683-689. doi:10.1377/hlthaff.2008.0567PubMedGoogle ScholarCrossref
7.
Hong  AS, Ross-Degnan  D, Zhang  F, Wharam  JF.  Clinician-level predictors for ordering low-value imaging.  JAMA Intern Med. 2017;177(11):1577-1585. doi:10.1001/jamainternmed.2017.4888PubMedGoogle ScholarCrossref
8.
van Biesen  T, Weisbrod  J, Brookshire  M, Coffman  J, Paternak  A. Front Line of Healthcare Report 2017. Bain & Co; 2017. http://www.bain.com/publications/articles/front-line-of-healthcare-report-2017.aspx. Accessed July 21, 2018.
9.
Federman  AD, Woodward  M, Keyhani  S.  Physicians’ opinions about reforming reimbursement: results of a national survey.  Arch Intern Med. 2010;170(19):1735-1742. doi:10.1001/archinternmed.2010.369PubMedGoogle ScholarCrossref
10.
Sirovich  BE, Woloshin  S, Schwartz  LM.  Too little? too much? primary care physicians’ views on US health care: a brief report.  Arch Intern Med. 2011;171(17):1582-1585. doi:10.1001/archinternmed.2011.437PubMedGoogle ScholarCrossref
11.
Polite  B, Conti  RM, Ward  JC.  Reform of the buy-and-bill system for outpatient chemotherapy care is inevitable: perspectives from an economist, a realpolitik, and an oncologist.  Am Soc Clin Oncol Educ Book. 2015:e75-e80. doi:10.14694/EdBook_AM.2015.35.e75PubMedGoogle Scholar
12.
Greenup  RA, Blitzblau  RC, Houck  KL,  et al.  Cost implications of an evidence-based approach to radiation treatment after lumpectomy for early-stage breast cancer.  J Oncol Pract. 2017;13(4):e283-e290. doi:10.1200/JOP.2016.016683PubMedGoogle ScholarCrossref
13.
Bekelman  JE, Sylwestrzak  G, Barron  J,  et al.  Uptake and costs of hypofractionated vs conventional whole breast irradiation after breast conserving surgery in the United States, 2008-2013.  JAMA. 2014;312(23):2542-2550. doi:10.1001/jama.2014.16616PubMedGoogle ScholarCrossref
14.
Konski  A, Yu  JB, Freedman  G, Harrison  LB, Johnstone  PAS.  Radiation oncology practice: adjusting to a new reimbursement model.  J Oncol Pract. 2016;12(5):e576-e583. doi:10.1200/JOP.2015.007385PubMedGoogle ScholarCrossref
15.
Self-referral Toolkit. American Society for Radiation Technology. https://www.astro.org/uploadedFiles/_MAIN_SITE/Advocacy/content_pieces/SelfReferralToolkit.pdf. Published February 2012. Accessed July 12, 2018.
16.
Robertson  C, Rose  S, Kesselheim  AS.  Effect of financial relationships on the behaviors of health care professionals: a review of the evidence.  J Law Med Ethics. 2012;40(3):452-466. doi:10.1111/j.1748-720X.2012.00678.xPubMedGoogle ScholarCrossref
17.
Scott  A, Sivey  P, Ait Ouakrim  D,  et al.  The effect of financial incentives on the quality of health care provided by primary care physicians.  Cochrane Database Syst Rev. 2011;(9):CD008451. doi:10.1002/14651858.CD008451.pub2PubMedGoogle Scholar
18.
Gosden  T, Forland  F, Kristiansen  IS,  et al.  Capitation, salary, fee-for-service and mixed systems of payment: effects on the behaviour of primary care physicians.  Cochrane Database Syst Rev. 2000;(3):CD002215. doi:10.1002/14651858.CD002215PubMedGoogle Scholar
19.
Rashidian  A, Omidvari  A-H, Vali  Y, Sturm  H, Oxman  AD.  Pharmaceutical policies: effects of financial incentives for prescribers.  Cochrane Database Syst Rev. 2015;(8):CD006731. doi:10.1002/14651858.CD006731.pub2PubMedGoogle Scholar
20.
Sterne  JA, Hernán  MA, Reeves  BC,  et al.  ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions.  BMJ. 2016;355(October):i4919. doi:10.1136/bmj.i4919PubMedGoogle ScholarCrossref
21.
Hadley  J, Mandelblatt  JS, Mitchell  JM, Weeks  JC, Guadagnoli  E, Hwang  YT; OPTIONS Research Team.  Medicare breast surgery fees and treatment received by older women with localized breast cancer.  Health Serv Res. 2003;38(2):553-573. doi:10.1111/1475-6773.00133PubMedGoogle ScholarCrossref
22.
Jacobson  M, O’Malley  AJ, Earle  CC, Pakes  J, Gaccione  P, Newhouse  JP.  Does reimbursement influence chemotherapy treatment for cancer patients?  Health Aff (Millwood). 2006;25(2):437-443. doi:10.1377/hlthaff.25.2.437PubMedGoogle ScholarCrossref
23.
Epstein  AJ, Johnson  SJ.  Physician response to financial incentives when choosing drugs to treat breast cancer.  Int J Health Care Finance Econ. 2012;12(4):285-302. doi:10.1007/s10754-012-9117-yPubMedGoogle ScholarCrossref
24.
Ellis  SD, Chen  RC, Dusetzina  SB,  et al.  Are small reimbursement changes enough to change cancer care? reimbursement variation in prostate cancer treatment.  J Oncol Pract. 2016;12(4):e423-e436. doi:10.1200/JOP.2015.007344PubMedGoogle ScholarCrossref
25.
Jung  J, Xu  WY, Kalidindi  Y.  Impact of the 340B drug pricing program on cancer care site and spending in Medicare.  Health Serv Res. 2018;53(5):3528-3548. doi:10.1111/1475-6773.12823Google ScholarCrossref
26.
Mitchell  JM, Sunshine  JH.  Consequences of physicians’ ownership of health care facilities—joint ventures in radiation therapy.  N Engl J Med. 1992;327(21):1497-1501. doi:10.1056/NEJM199211193272106PubMedGoogle ScholarCrossref
27.
Smith  BD, Pan  I-W, Shih  Y-CT,  et al.  Adoption of intensity-modulated radiation therapy for breast cancer in the United States.  J Natl Cancer Inst. 2011;103(10):798-809. doi:10.1093/jnci/djr100PubMedGoogle ScholarCrossref
28.
Bekelman  JE, Suneja  G, Guzzo  T, Pollack  CE, Armstrong  K, Epstein  AJ.  Effect of practice integration between urologists and radiation oncologists on prostate cancer treatment patterns.  J Urol. 2013;190(1):97-101. doi:10.1016/j.juro.2013.01.103PubMedGoogle ScholarCrossref
29.
Mitchell  JM.  Urologists’ use of intensity-modulated radiation therapy for prostate cancer.  N Engl J Med. 2013;369(17):1629-1637. doi:10.1056/NEJMsa1201141PubMedGoogle ScholarCrossref
30.
Williams  SB, Huo  J, Chapin  BF, Smith  BD, Hoffman  KE.  Impact of urologists’ ownership of radiation equipment in the treatment of prostate cancer.  Prostate Cancer Prostatic Dis. 2017;20(3):300-304. doi:10.1038/pcan.2017.9PubMedGoogle ScholarCrossref
31.
Elliott  SP, Jarosek  SL, Wilt  TJ, Virnig  BA.  Reduction in physician reimbursement and use of hormone therapy in prostate cancer.  J Natl Cancer Inst. 2010;102(24):1826-1834. doi:10.1093/jnci/djq417PubMedGoogle ScholarCrossref
32.
Jacobson  M, Earle  CC, Price  M, Newhouse  JP.  How Medicare’s payment cuts for cancer chemotherapy drugs changed patterns of treatment.  Health Aff (Millwood). 2010;29(7):1391-1399. doi:10.1377/hlthaff.2009.0563PubMedGoogle ScholarCrossref
33.
Jacobson  M, Earle  CC, Newhouse  JP.  Geographic variation in physicians’ responses to a reimbursement change.  N Engl J Med. 2011;365(22):2049-2052. doi:10.1056/NEJMp1110117PubMedGoogle ScholarCrossref
34.
Colla  CH, Morden  NE, Skinner  JS, Hoverman  JR, Meara  E.  Impact of payment reform on chemotherapy at the end of life.  J Oncol Pract. 2012;8(3)(suppl):e6s-e13s. doi:10.1200/JOP.2012.000539PubMedGoogle ScholarCrossref
35.
Conti  RM, Rosenthal  MB, Polite  BN, Bach  PB, Shih  Y-CT.  Infused chemotherapy use in the elderly after patent expiration.  J Oncol Pract. 2012;8(3)(suppl):e18s-e23s. doi:10.1200/JOP.2012.000541PubMedGoogle ScholarCrossref
36.
Quek  RGW, Master  VA, Portier  KM,  et al.  Association of reimbursement policy and urologists’ characteristics with the use of medical androgen deprivation therapy for clinically localized prostate cancer.  Urol Oncol. 2014;32(6):748-760. doi:10.1016/j.urolonc.2014.02.017PubMedGoogle ScholarCrossref
37.
Shahinian  VB, Kuo  Y-F.  Reimbursement cuts and changes in urologist use of androgen deprivation therapy for prostate cancer.  BMC Urol. 2015;15:25. doi:10.1186/s12894-015-0020-yPubMedGoogle ScholarCrossref
38.
O’Neil  B, Graves  AJ, Barocas  DA, Chang  SS, Penson  DF, Resnick  MJ.  Doing more for more: unintended consequences of financial incentives for oncology specialty care.  J Natl Cancer Inst. 2015;108(2):djv331. doi:10.1093/jnci/djv331PubMedGoogle Scholar
39.
Shumway  DA, Griffith  KA, Pierce  LJ,  et al.  Wide variation in the diffusion of a new technology: practice-based trends in intensity-modulated radiation therapy (IMRT) use in the state of Michigan, with implications for IMRT use nationally.  J Oncol Pract. 2015;11(3):e373-e379. doi:10.1200/JOP.2014.002568PubMedGoogle ScholarCrossref
40.
Roberts  KB, Soulos  PR, Herrin  J,  et al.  The adoption of new adjuvant radiation therapy modalities among Medicare beneficiaries with breast cancer: clinical correlates and cost implications.  Int J Radiat Oncol Biol Phys. 2013;85(5):1186-1192. doi:10.1016/j.ijrobp.2012.10.009PubMedGoogle ScholarCrossref
41.
Mitchell  JM.  The prevalence of physician self-referral arrangements after Stark II: evidence from advanced diagnostic imaging.  Health Aff (Millwood). 2007;26(3):w415-w424. doi:10.1377/hlthaff.26.3.w415PubMedGoogle ScholarCrossref
42.
Desch  CE, Blayney  DW.  Making the choice between academic oncology and community practice: the big picture and details about each career.  J Oncol Pract. 2006;2(3):132-136. doi:10.1200/jop.2006.2.3.132PubMedGoogle ScholarCrossref
43.
Chang  SL, Liao  JC, Shinghal  R.  Decreasing use of luteinizing hormone-releasing hormone agonists in the United States is independent of reimbursement changes: a Medicare and Veterans Health Administration claims analysis.  J Urol. 2009;182(1):255-260. doi:10.1016/j.juro.2009.02.141PubMedGoogle ScholarCrossref
44.
Ellis  SD, Nielsen  ME, Carpenter  WR,  et al.  Gonadotropin-releasing hormone agonist overuse: urologists’ response to reimbursement and characteristics associated with persistent overuse.  Prostate Cancer Prostatic Dis. 2015;18(2):173-181. doi:10.1038/pcan.2015.10PubMedGoogle ScholarCrossref
45.
Feinberg  B, Milligan  S, Olson  T,  et al.  Physician behavior impact when revenue shifted from drugs to services.  Am J Manag Care. 2014;20(4):303-310.PubMedGoogle Scholar
46.
Gawade  PL, Berlin  JA, Henry  DH,  et al.  Changes in the use of erythropoiesis-stimulating agents (ESAs) and red blood cell transfusion in patients with cancer amidst regulatory and reimbursement changes.  Pharmacoepidemiol Drug Saf. 2017;26(11):1357-1366. doi:10.1002/pds.4293PubMedGoogle ScholarCrossref
47.
Hershman  DL, Neugut  AI, Shim  JJ, Glied  S, Tsai  W-Y, Wright  JD.  Erythropoiesis-stimulating agent use after changes in Medicare reimbursement policies.  J Oncol Pract. 2014;10(4):264-269. doi:10.1200/JOP.2013.001255PubMedGoogle ScholarCrossref
48.
Hess  G, Nordyke  RJ, Hill  J, Hulnick  S.  Effect of reimbursement changes on erythropoiesis-stimulating agent utilization and transfusions.  Am J Hematol. 2010;85(11):838-843. doi:10.1002/ajh.21837PubMedGoogle ScholarCrossref
49.
Loy  BA, Shkedy  CI, Powell  AC,  et al.  Do case rates affect physicians’ clinical practice in radiation oncology?: an observational study.  PLoS One. 2016;11(2):e0149449. doi:10.1371/journal.pone.0149449PubMedGoogle ScholarCrossref
50.
American Medical Association Code of Medical Ethics. https://www.ama-assn.org/delivering-care/conflicts-interest-patient-care. Accessed July 13, 2018.
51.
Becker  GS.  The Economic Approach to Human Behavior. Chicago, IL: University of Chicago Press; 2008.
52.
Pollack  CE, Soulos  PR, Gross  CP.  Physician’s peer exposure and the adoption of a new cancer treatment modality.  Cancer. 2015;121(16):2799-2807. doi:10.1002/cncr.29409PubMedGoogle ScholarCrossref
53.
Ost  DE, Niu  J, Elting  LS, Buchholz  TA, Giordano  SH.  Determinants of practice patterns and quality gaps in lung cancer staging and diagnosis.  Chest. 2014;145(5):1097-1113. doi:10.1378/chest.13-1628PubMedGoogle ScholarCrossref
54.
Churilla  TM, Egleston  B, Bleicher  R, Dong  Y, Meyer  J, Anderson  P.  Disparities in the local management of breast cancer in the us according to health insurance status.  Breast J. 2017;23(2):169-176. doi:10.1111/tbj.12705PubMedGoogle ScholarCrossref
55.
US Federal Register. Medicare Program: Part B Drug Payment Model. https://www.federalregister.gov/documents/2016/03/11/2016-05459/medicare-program-part-b-drug-payment-model. Published March 11, 2016. Accessed July 13, 2018.
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
If you are not a JN Learning subscriber, you can either:
Subscribe to JN Learning for one year
Buy this activity
jn-learning_Modal_Multimedia_LoginSubscribe_Purchase
Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close

Name Your Search

Save Search
Close
With a personal account, you can:
  • Track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
jn-learning_Modal_SaveSearch_NoAccess_Purchase
Close

Lookup An Activity

or

Close

My Saved Searches

You currently have no searches saved.

Close
With a personal account, you can:
  • Access free activities and track your credits
  • Personalize content alerts
  • Customize your interests
  • Fully personalize your learning experience
Education Center Collection Sign In Modal Right
Close