Incentive payments to primary care physicians for providing comprehensive, guideline-based care to patients with complex illness did not improve quality of care or reduce hospital admissions in British Columbia, according to a study published in the Canadian Medical Association Journal.
While patients with multiple chronic medical conditions make up only 12% of the Canadian population, they drive a sizeable proportion of health care use. Complex patients account for nearly one-quarter of physician consultations and half of hospital days in Canada. To address nationwide poor performance in coordination, accessibility, and quality of care for complex patients, British Columbia implemented an incentive payment program to improve primary care quality in this population.1
“More than $240 million was spent on the Complex Care Initiative between 2007 and 2013. Despite this investment, its impact on primary care delivery, hospital admissions, and costs has not been rigorously assessed,” the authors, led by M. Ruth Lavergne, PhD, of Simon Fraser University in British Columbia, wrote.
Dr Lavergne and colleagues analyzed the primary care contacts, hospital admissions, and cost of health care services 24 months before and 24 months after the intervention — a comprehensive, guideline-based care plan — was implemented in patients with 2 or more chronic illnesses. Chronic diseases targeted by the program included congestive heart failure, ischemic heart disease, chronic kidney disease, diabetes, chronic obstructive pulmonary disease, asthma, and cerebrovascular disease.
At least 1 incentive payment was billed for 63.7% of 155,754 patients with 2 or more chronic conditions. Incentive payments did not improve access to primary care or continuity of care: the mean monthly change was 0.016 (95% confidence interval [CI], -0.047 to 0.078) for number of primary care contacts per month and 0.012 (95% CI, -0.001 to 0.024) for proportion of visits to the same provider.
Rates of hospital admission increased (change in hospital admissions per 1000 patients per month: 1.46; 95% CI, 0.04 to 2.89), and no cost savings were observed (mean change in annual costs per patient: $455.81; 95% CI, -$2.44 to $914.08).
Dr Lavergne and colleagues concluded that “British Columbia’s $240-million investment in this program may have improved compensation for physicians doing the important work of caring for patients with complex illness, but has not yielded measurable improvements in the outcomes examined. Other strategies are needed to improve care for this patient group.”
This study, however, does have important limitations. “Post-hoc evaluations of policy are tricky because the objectives are often unclear, the most relevant clinical data is usually unavailable and it is impossible to disentangle the effects of the policy from other factors influencing outcomes,” Tara Kiran, MD, MSc, of St. Michael’s Hospital, University of Toronto, wrote in a related editorial in the Canadian Medical Association Journal.2
“A lot of money was spent on the incentives in British Columbia, and this money could have been used elsewhere in the healthcare system,” Dr Kiran said in an interview with Neurology Advisor. “The authors did this study to figure out whether the incentives improved things, but it’s hard to evaluate policy changes after the fact. Given our limited resources, governments and physician associations should be transparent about the goals of payment reform, commission evaluations at the start, and be open to changes based on evaluation results.”
This study was funded by a grant from the Canadian Institutes of Health Research. The authors report no relevant disclosures.
- Lavergne MR, Law MR, Peterson S, Garrison S, Hurley J, Cheng L, McGrail K. A population-based analysis of incentive payments to primary care physicians for the care of patients with complex disease. CMAJ. 2016 Aug 15. Published online ahead of print. doi:10.1503/cmaj.150858.
- Kiran T. Toward evidence-based policy. CMAJ. 2016 Aug 15. Published online ahead of print. doi:10.1503/cmaj.160692.