Physician perception of reimbursement for outpatient procedures among managed care patients with diabetes mellitus.

Ideally, physician test-ordering is determined by clinical factors, such as patient symptoms or disease screening recommendations. In reality, healthcare is delivered in a complex environment that exposes the physician to a wide range of non-clinical factors1–4 which may influence test-ordering behavior. These competing influences may be especially strong for primary care physicians, who diagnose and treat a wide array of diseases. Patients, patient advocates, policy-makers, and healthcare organizations attempt to manage these non-clinical influences to elicit their preferred version of test-ordering behavior. One of these influences is reimbursement. Reimbursement initiatives are predicated by the assumption that if physicians perceive financial rewards for ordering a particular test, this perception will affect their test-ordering behavior.5 Few studies have examined the association between primary care physician reimbursement perceptions and performance of particular procedures. Epstein and colleagues compared test performance in fee-for-service patients to test performance in managed care enrollees.6, 7 Their hypothesis was that reimbursement perceptions would be stronger in fee-for-service plans than in managed care plans, and thus fee-for-service patients would receive more tests. After adjustment for physician years in practice and patient age, sex, duration of disease, and blood pressure levels, they found that tests perceived as more profitable (i.e., electrocardiograms) were performed more frequently by physicians in fee-for-service settings than in managed care plans. Tests perceived as less profitable, such as urinalyses and radiographs, did not differ in frequency between managed care and fee-for-service. Thus, perceived reimbursement appeared to play a role in test-ordering practices. More recent studies have examined actual reimbursement, as opposed to perceived reimbursement.8, 9 These reports have focused on procedure performance in fee-for-service vs. salaried or capitated systems,8 and more recently, specific pay-for-performance initiatives.9 While such studies examine performance of procedures in different financial systems, they have usually not queried physicians on their reimbursement perceptions. Reimbursement perceptions may better predict actual test-ordering behavior because physicians may have limited awareness of actual reimbursement; in one survey, 16% of physicians did not know the percent of their compensation from salary.15 In other studies, physicians were unaware of added reimbursement for vaccinations and cancer screening.10, 11 Since the studies by Epstein and colleagues, the health care environment has changed; the current health care market has higher managed care penetration12 and physician groups may contract with both fee-for-service and managed care plans. In addition, pay-for-performance programs may currently affect more than 80% of managed care enrollees.9 To our knowledge, the association between physician reimbursement perceptions and test performance has not been examined in this environment. Such an examination would inform our understanding of the importance of reimbursement perceptions in the clinical decision-making process. Therefore, we tested the hypothesis that the patients of physicians who perceived reimbursement for a particular procedure were more likely to have received that procedure than those whose physicians did not perceive reimbursement for the procedure. We used detailed clinical data from Translating Research into Action (TRIAD), a large cohort study of managed care enrollees with diabetes and their physicians enrolled in multiple health plans.