A recent systematic review found that several studies in the literature showed an association between various physician treatment practices in oncology and reimbursement, suggesting that financial incentives may influence oncologists' practice patterns in the U.S. (JAMA Oncol 2019; doi:10.1001/jamaoncol.2018.6196). Overall, the study findings indicate that shifting physician reimbursement from the traditional fee-for-service model to value-based care could remedy misaligned financial incentives among physicians and ultimately provide patients with higher quality care.
Mining the Literature
Study authors systematically reviewed the literature for studies that assessed the association between physician reimbursement and the delivery of various cancer treatment services in the U.S. Five databases, including PubMed/MEDLINE, Web of Science, Proquest Health Management, Econlit, and Business Source Premier, were used to search for journal articles.
To account for possible bias in the studies, the risk of bias was calculated for each study using the Risk of Bias in Non-Randomized Studies of Interventions tool, and each study was assigned an overall risk of bias score. On the basis of risk of bias score, studies were categorized as low, moderate, high, critical, or unclear.
A total of 25 studies from the literature were assessed for their risk of bias. Seven had a critical risk of bias score, however, and were therefore excluded from analysis, leaving 18 for inclusion. Of the 18 studies included, 14 had a moderate risk of bias and four had a high risk of bias.
“This study does a very nice job of assessing the risk of bias in these studies,” commented Lindsay Sabik, PhD, Associate Professor in the Department of Health Policy and Management at the University of Pittsburgh Graduate School of Public Health, during an interview with Oncology Times. The use of observational studies was not a concern. “One limitation to this area of research is that it's very difficult, if not impossible, to randomize physicians to different types of payment arrangements,” she noted.
No date restrictions were imposed on included studies, and most studies (15 of 18) were published in 2010 or later. Studies covered a range of cancer types, including prostate cancer (seven studies), breast cancer (three studies), lung cancer (two studies), bladder cancer (one study), and colorectal cancer (one study). Four studies covered multiple types of cancer.
A spectrum of associations between physician reimbursement and delivery of cancer treatment services were revealed across several studies.
Among studies focused on differential compensation between physicians or treatments, four studies reported associations between physician reimbursement and choice of treatment. For example, one study involving breast cancer showed that physicians had a greater likelihood of choosing breast-conserving surgery followed by adjuvant radiotherapy over mastectomy if they were reimbursed at a higher rate for breast-conserving surgery or a lower rate for mastectomy. Beyond that, two studies showed that when physicians recommended systemic therapy, they favored treatment options with a higher reimbursement rate. Similarly, one study showed a tendency to administer therapies in costly, more-profitable hospital outpatient facilities over office clinics.
Across five studies that examined practice structure, physicians who belonged to a practice that financially profited from self-referral for radiotherapy or who practiced at a freestanding radiotherapy center were consistently found to have a higher likelihood of using radiotherapy for their patients. Furthermore, compared with practices that self-refer for radiotherapy, patients treated at freestanding radiotherapy centers were more likely to undergo not only any type of radiotherapy but also intensity-modulated radiotherapy, which has a higher reimbursement rate than conventional radiotherapy. One study in particular found that for prostate cancer, the increased likelihood of receiving radiotherapy at a practice that self-refers for the service may in fact replace the receipt of other interventions, namely, prostatectomy and androgen-deprivation therapy.
Among studies investigating changes in physician compensation for treatments over time, six studies found that changes in physician reimbursement for treatments was associated with the choice of treatment. For instance, two studies investigating the use of androgen-deprivation therapy for prostate cancer found that after the Medicare Modernization Act of 2003 (MMA) took effect, the use of androgen-deprivation therapy decreased. (One study examining the same subject, however, found no such association.) One study found that, after the MMA, physicians responded by reducing their prescribing of medications that had the greatest decrease in profitability. A different study showed that when the patent for irinotecan expired and a generic alternative entered the market, physicians prescribed the oncolytic less often.
“While the research on reimbursement incentives and physician practice in oncology is somewhat limited, the existing studies that they reviewed really consistently point to the importance of financial incentives in oncology care,” Sabik said.
“The takeaway from this paper for me is that payment policies that appropriately align financial incentives with care quality are important and could reduce overuse of costly therapies and risk to patients from potential overtreatment.”
In light of these findings, the study researchers advocated for value-based reimbursement, asserting that such a model “may be a useful tool to better align physician incentives with patient need and increase the value of oncology care.”
Sabik shared a similar view, saying, “The findings summarized here definitely highlight the need for ongoing efforts to shift from volume-based to value-based reimbursement.”
However, the study authors acknowledged that most of the studies they reviewed examined policy changes or payment models that are no longer in effect. About this gap in research, Sabik said, “This also really draws attention to the need for more research on the role of incentives in the current context, particularly with rapidly evolving treatment technologies and increasing use of high-cost targeted and immunotherapy agents.”
Christina Bennett is a contributing writer.