Ryskina KL, Bishop TF. Physicians’ Lack of Awareness of How They Are Paid: Implications for New Models of Reimbursement. JAMA Intern Med. 2013;173(18):1745-1746. doi:10.1001/jamainternmed.2013.9270
As pay-for-performance initiatives continue to propagate throughout the health care system, studies report mixed findings regarding their effect on physician behavior and patient outcomes.1,2 One possible reason that pay-for-performance efforts have failed is that physicians might not know about the incentives. Although some early reports have commented on a lack of physician awareness of pay-for-performance programs even in the setting of controlled research interventions,3- 5 physician awareness of incentives has not been assessed on a national scale. Using data from a national survey of physicians, we looked at physician awareness of pay-for-performance.
We performed a cross-sectional analysis using the 2007-2008 National Ambulatory Medical Care Survey (NAMCS), which is a nationally representative survey administered by the Centers for Disease Control and Prevention’s National Center for Health Statistics. The NAMCS is a survey of nonfederal, non–hospital-based physicians who see patients in the ambulatory setting. The NAMCS uses a complex sampling design with physician weighting so that national estimates of physician and practice characteristics can be reliably generated. The institutional review board at Weill Cornell Medical College approved this study.
Physicians were asked whether they received some compensation for quality or patient satisfaction. All percentages reported represent nationally weighted data. We performed multivariate logistic regression to identify which physician and practice characteristics (US region, urban vs rural setting, practice ownership, solo vs group, specialty, and practice model [eg, private practice, health maintenance organization]) were independently associated with a physician’s lack of awareness of incentive payments.
Analyses were performed using Stata statistical software (version 12.0; StataCorp).
In 2007 to 2008, 2545 eligible physicians completed the NAMCS induction survey. The proportion of physicians who received some compensation for quality was 21.5% (95% CI, 18.9%-24.0%) and the proportion for patient satisfaction was 18.7% (95% CI, 16.3%-21.1%). An almost similar percentage of physicians did not know whether they received compensation for quality (16.2% [95% CI, 13.1%-19.2%]) or patient satisfaction (16.0% [95% CI, 13.0%-19.0%]). Physicians who did not know whether their compensation was linked to quality were more likely to practice in an urban setting (adjusted odds ratio [AOR], 2.50 [95% CI, 1.36-4.56]), more likely to practice in a freestanding clinic or urgicenter (AOR, 2.01 [95% CI, 1.07-3.78]), and less likely to practice in a community health center (AOR, 0.16 [95% CI, 0.06-0.42]) vs private practice. Physicians who did not know whether their compensation was linked to patient satisfaction were also more likely to practice in an urban setting (AOR, 2.24 [95% CI, 1.30-3.85]) and less likely to practice in a community health center (AOR, 0.17 [95% CI, 0.07-0.42]) vs private practice (Table).
In a national survey of physicians, 1 in 6 did not know whether pay-for-performance was incorporated into their compensation. These findings support previous reports from smaller samples showing a lack of awareness about pay-for-performance initiatives.3- 5 These findings suggest an important mechanism underlying the relative ineffectiveness of financial incentives in changing physician behavior and improving quality of care: physicians may be unaware of these incentives. If payers want pay-for-performance programs to be more effective, they may need to ensure that physicians understand what the incentives are and how they might affect their compensation.
The years of the NAMCS survey used for this study were soon after the implementation of the Physician Quality Reporting System, a program by the Centers for Medicare and Medicaid Services that provides financial incentives for reporting quality measures. Given this proximity, it is unclear whether our findings reflect physician awareness after this program was implemented. Future research should aim to assess physician awareness of incentive compensation given this and other rapidly changing incentive programs.
Corresponding Author: Tara F. Bishop, MD, MPH, Department of Public Health, Weill Cornell Medical College, 402 E 67th St, Room LA-218, New York, NY 10065 (firstname.lastname@example.org).
Published Online: August 12, 2013. doi:10.1001/jamainternmed.2013.9270.
Author Contributions: Dr Ryskina 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.
Study concept and design: Both authors.
Acquisition of data: Bishop.
Analysis and interpretation of data: Both authors.
Drafting of the manuscript: Ryskina.
Critical revision of the manuscript for important intellectual content: Bishop.
Statistical analysis: Ryskina.
Administrative, technical, and material support: Bishop.
Study supervision: Bishop.
Conflicts of Interest Disclosures: None reported.
Funding/Support: Dr Bishop is supported by a National Institute on Aging Career Development Award (K23AG043499) and as a Nanette Laitman Clinical Scholar in Public Health at Weill Cornell Medical College.
Disclaimer: The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.