Pay for performance scheme for Ont. MDs cost $110 million, didn't work: study

TORONTO - An incentive program that pays Ontario doctors extra for persuading patients to get screened for certain cancers shelled out $110 million over three years — but it did not result in significant increases in the number of people going for the tests, a new study reveals.

The study, by researchers at the Li Ka Shing Knowledge Institute at Toronto's St. Michael's Hospital, looked at a so-called pay for performance program Ontario instituted in 2006-2007 to try to increase rates of screening for three types of cancers — colorectal, cervical and breast cancer.

Family doctors who hit certain thresholds in terms of the percentage of their patients who underwent age- and gender-appropriate screening tests were able to bill the province for bonuses. In 2009-10 doctors who hit the highest targets for all three types of screening could claim an additional $8,400.

Over three years studied — 2006-2007 through 2009-2010 — the incentive program paid out just under $110 million, with $28.3 million, $31.3 million and $50.0 million spent on bonuses for cervical, breast and colorectal cancer screening, respectively.

But when the researchers looked to see if the rates of people being screened for these cancers rose during that time, they found two virtually flat lines — for cervical and breast cancer screening — and some modest improvement for colorectal cancer screening.

Lead author Dr. Tara Kiran said when the program was instituted colorectal cancer screening rates were rising at about three per cent a year. After the incentive scheme was put in place, that increased to about 4.7 per cent growth a year. But over the same time period Cancer Care Ontario had a big publicity push to educate the public about the values of screening for colorectal cancer.

As a result, it's unclear the increase can be attributed to the pay for performance program, said Kiran, a family physician and researcher who studies the impact of primary care reforms on the quality of care.

"We can't tease out the effects of other interventions that happened around the same time."

Kiran and her co-authors said that there has been a lot of enthusiasm internationally for the notion of pay for performance programs as a means to improve health-care delivery. But she said there has actually been little evidence about whether the schemes really work.

In the last year of the study, 84 per cent of eligible physicians — 4,992 doctors — submitted a bill for at least one of the three cancer screening incentive billing codes. And 22 per cent or 1,278 billed the highest amount for all three screening incentives. Even at the top rate, however, the bonuses only made up about three per cent of a doctor's gross income.

Kiran suggested the discrepancy — significant payouts, but no real screening increases — is probably due to the fact that the doctors who billed were already doing a good job referring patients for cancer screening. It's just that after the program came into effect they got paid a premium for work they had been doing all along.

"Our findings suggest that the bonuses may in fact have been targeting the wrong doctors," said Kiran.

"I think pay for performance works on the premise that more money will motivate doctors to provide better care. But motivation may not be the issue."

She suggested fixing system problems — such as electronic medical records that do not automatically generate reminders that Patient X is due to have a screening test — might make more headway.

Health economist Steven Lewis suggested it's not a surprise the program didn't have the desired effect. He said other studies have shown that simple financial incentives are not the way to steer doctors toward delivering better care.

Lewis said the Ontario government should consider this study the next time it negotiates a fee schedule with the Ontario Medical Association.

"When the government and the OMA sit down, I think they need to fundamentally rethink what road they have gone down in terms of pay for performance to acknowledge what the preponderance of (scientific) literature says," Lewis said. "And start appealing to what's good and motivated in clinical practice, and not assuming that the prospect of additional income is going to have either a significant or a durable effect."

He said the public should actually feel good about what this study says about doctors.

"In a way it's a bad news story in that they wasted the money, but it's actually a good news story," said Lewis, an independent consultant based in Saskatoon.

"The assumption that health care is like Wall Street and physicians are Gordon Gekko wannabes has always been implausible. We should rejoice in the study results — if it had found that physicians will not improve performance unless you pay them great gobs of money on top of their top one per cent incomes, it would be even worse."

The study was published in the journal Annals of Family Medicine. Financial support for the work came from the Toronto-based Institute for Clinical Evaluative Sciences, which is funded by an annual grant from the Ontario Ministry of Health and Long-Term Care.