Federman - Physicians' Opinions About Reforming Reimbursement

8/12/2019 Federman - Physicians' Opinions About Reforming Reimbursement

1/8

HEALTHCAREREFORM

ORIGINAL INVESTIGATION

Physicians Opinions About Reforming Reimbursement

Results of a National Survey

Alex D. Federman, MD, MPH; Mark Woodward, PhD; Salomeh Keyhani, MD, MPH

Background:Several strategies have been proposed toreform physician reimbursement while improving qual-ity of care. Despite much debate, physicians opinions re-garding reimbursement reform proposals have not beenobjectively assessed.

Methods:We conducted a national survey of ran-domly selected physicians between June 25 and Octo-

ber 31, 2009. Physicians rated their support for severalreimbursement reform proposals: rewarding quality withfinancial incentives, bundling payments for episodes ofcare, shifting payments from procedures to manage-ment and counseling services, increasing pay to gener-alists, and offsetting increased pay to generalists with areduction in pay for other specialties. Support for the dif-ferent reform options wascompared with physician prac-tice characteristics.

Results:The response rate was 48.5% (n=1222). Fourof 5 physicians (78.4%) indicated that under Medicare,

some procedures are compensated too highly and oth-ers are compensated at rates insufficient to cover costs.Incentives were themost frequently supportedreformop-tion (49.1%), followed by shifting payments (41.6%) andbundling (17.2%). Shifting payments and bundling weremore commonly supported by generalists than by other

specialists. There was broad support for increasing payfor generalists (79.8%), but a proposal to offset the in-crease with a 3% reduction in specialist reimbursementwas supported by only 39.1% of physicians.

Conclusions:Physicians are dissatisfied with Medicarereimbursement and show little consensus for major pro-posals to reform reimbursement. The successful adop-tion of payment reform proposals may require a betterunderstanding of physicians concerns and their willing-ness to make tradeoffs.

Arch Intern Med. 2010;170(19):1735-1742

ACROSS THE POLITICAL SPEC-trum, there is generalagreement that the cost ofhealth care has risen to un-tenablelevelsand is threat-

ening the future of Medicare and the eco-nomic well-being of the United States.1,2

These concerns have prompted various

proposals intended to bend the costcurve of health care expenditures whilemaintainingor improving health carequal-ity. Physicians account for only one-fifthof health care costs, but their clinical de-cisions and patterns of use are a major fac-tor in rising health care costs; thus, manyproposals have eyed physician reimburse-ments as potential targets to promote costsavings and establish incentives to im-prove care.3,4

A variety of strategies have been pro-posed to reform physician payment.5 Onewidely advocated approach is the use offinancial incentives, such as bonuses (payfor performance) for meeting quality stan-dards that reflect good process of care or

good health outcomes6 or financialpenalties for delivering substandard care,as measured by high hospital readmis-sion rates.7,8 Also gaining considerable at-tention are 2 strategies to promote greateraccountability by physicians or health caresystems for quality andcost: bundling pay-ments and promotion of accountable careorganizations.2,7,9 Bundling lays the re-sponsibility for containing costs and en-suring quality on the physician or healthcare system by paying a fixed amount for

See also page 1728

See Invited Commentaryat end of article

Author Affiliations:Division ofGeneral Internal Medicine(Drs Federman, Woodward, andKeyhani) and Department ofHealth Policy (Dr Keyhani),Mount Sinai School ofMedicine, New York, New York;and James J. Peters VeteransAdministration Medical Center,Bronx, New York (Dr Keyhani).

ARCH INTERN MED/ VOL 170 (NO. 19), OCT 25, 2010 WWW.ARCHINTERNMED.COM1735

2010 American Medical Association. All rights reserved.(REPRINTED WITH CORRECTIONS)

wnloaded From: http://archinte.jamanetwork.com/ by a Johns Hopkins University User on 01/22/2014


2/8

an episode of care or for a set of services bundled undera specific episode of care, much in the way that hospi-tals are reimbursed for care bundled under the inpatientprospective care system.10,11 Similarly, accountable careorganizations, which are extended networks of hospi-tals and outpatient providers, would have responsibilityfor total health care spending and quality of care for aset of patients. Bundling of services and accountable careorganizations are both promoted in the Patient Protec-tion and Accountable Care Act of 2010.12

Finally, the Patient Protection and Accountable CareAct also addresses the growing need for preventive careand care coordination by inceasing Medicare and Med-icaid payments to generalist physicians.12 Additionally,the Center for Medicare and Medicaid Services recentlyannounced plans to expand multiple procedure pay-ment reduction for imaging and therapy services.13 Com-bined, these strategies aim to increase the provision ofpreventive health care, promote health maintenance, andreduce excesive testing.14

Given the controversies in modifying paymentsto phy-sicians to controlcosts,policymakers shouldconsider howphysicians view the different options. Physicians expe-riences may help optimize the design of reimbursementreforms. In addition, maximizing physicians approval ofreforms would facilitate implementation. Although pre-vious research has assessed physicians views on healthcare system financing options, to our knowledge,15 therehave been no systematic evaluations of physicians viewson reimbursement reform. We, therefore, conducted anational survey to assess physicians opinions about dif-ferent strategies to reform physician reimbursement, pro-mote quality of care, and enhance health care savings.

METHODS

SAMPLE

In April 2009, we obtained data on a stratified sample of 6000physicians randomly selected from among 849 213 physicians inthe American Medical Association (AMA) Physician Masterfile.The AMA Physician Masterfile includes current data on all USphysicians, regardless of AMA affiliation. Physicians were strati-fied into 4 specialty groups:primary care(internists,familyprac-titioners, and pediatricianswithout subspecialtytraining); medi-cal and pediatrics subspecialists, neurologists, and psychiatrists;surgical specialists and subspecialists (general surgeons, surgi-cal subspecialists, and obstetrician/gynecologists); and the re-maining specialties. Equal numbers of physicians were ran-domly sampled for eachstratum. The study was approved by theMount Sinai School of Medicine institutional review board.

SURVEY DEVELOPMENT

We empanelled 7 nationally recognized physician leaders andhealth policy and survey research experts and engaged themin a modified Delphi process to develop content for the sur-vey.16We drafted survey questions and asked the expert panelto rank these items by policy relevance. To refine the ques-tions and uncover new themes, we conducted 1-to-1 cognitiveinterviews with 16 physicians from 7 statesin personor by tele-phone.Physicianswere selected from a variety of practice back-grounds (private practice, salaried physicians, practice own-

ers, and hospitalists) and specialty backgrounds (primary careproviders and medical and surgical subspecialists). The sur-vey questions were refined through this process until no newcontent themes and no misinterpretations of the survey itemswere identified.The survey was pilot tested on 15 internal medi-cine physicians at Mount Sinai Hospital and had an averagecompletion time of less than 4 minutes.

SURVEY ADMINISTRATION

We adopted the total design method to optimize the physiciansurvey response.17-22 This approach minimized respondent bur-den by using a brief (3-page, 4-minute) survey with personal-ized content (a personalizedletter, a signedcoverletter, andpost-age stamps) and follow-up contacts. The survey was mailed in 3waves. Thefirst wave included a cover letter,thesurvey,a stampedreturn envelope, and a $2 bill. Subsequent waves didnot includea monetary incentive. Physicians were called after eachwave wasmailed to encourage them to complete thesurveyand to offer themthe option of returning it by fax or by e-mail.

Physicians were randomly chosen to receive 1 of 2 ver-sions of the survey. The 2 versions shared corecontent (eg, opin-ions about insurance coverage expansions and practice and pro-fessional characteristics) but differed by 4 to 6 supplementalquestions, including questions about physician reimburse-ment. Thus, approximately half of the sample was asked aboutreimbursement. Thefirstof 3 survey waves of theNationalPhy-sicians Survey on Health Care Reform began on June 25, 2009,and the third survey wave was initiated on August 27, 2009.Data collection was completed on October 31, 2009.

OUTCOME MEASURES

The survey included 6 questions about physicians opinions re-garding reimbursement and reimbursement reform proposals(eAppendix; http://www.archinternmed.com). The first ques-tion addressed equitability of Medicare reimbursements by ask-ing physicians to express their level of agreement with the fol-lowing statement: With the current Medicare reimbursementsystem, some proceduresare compensatedtoo highly and oth-ers are compensated at rates insufficient to cover costs. Re-sponseoptions on the 5-point Likert scale rangedfrom stronglyagree (5) to strongly disagree (1). Next, we asked physiciansto express their level of support for 3 proposals for reformingreimbursement: rewardingquality withfinancial incentives, bun-dling paymentsfor episodes of care, and shiftingpayments fromprocedural care to management and counseling services.

Variables captured on both surveyversionsincluded time spenton clinical dutieseachweek, practiceownership, paymentmecha-nism (salary only, salary andbonus, from billing only, shift orhourly wage, or other), and professional society affiliation. Dataobtained from the AMA Physician Masterfile included date ofbirth, sex, state,zip code, specialty, training level (current traineeor training completed), and type of practice (office based, hos-pital based, administrative, teaching, research, resident, locumtenems, or other).Zip code data wereused to determine whether

the practice site was rural or urban.

STATISTICAL ANALYSIS

TheanalysesexcludedphysiciansfromUSterritoriesbecausehealthcarereformmaynotbeasrelevanttothemandphysiciansintrain-ing because of their limited experience with reimbursement. Wecalculatedtheresponse andrefusal rates using standardmethods,23

and we compared the characteristics of respondents and nonre-spondents usingt and2 tests anddata available in theAMA Phy-sician Masterfile. The associations between support for the pro-





3/8

posedreformsand physicianspecialtyand practice characteristicswereevaluatedusinglogisticregressionadjustingforphysicianprac-ticecharacteristics.Fortheregressionanalyses,the5outcomes(sup-portfordifferentpayment reforms and increased payment for pri-mary care) were dichotomized as strongly or somewhat supportvs unsure or do not support. Weights were used to adjust for the

stratifiedsamplingdesign,andalltheanalyseswereperformedusingthe survey sampling and analysis procedures in SAS version 9.1(SAS Institute Inc, Cary, North Carolina).

RESULTS

SURVEY RESPONSE

Of the 6000 physicians, 794 (13.2%) were trainees, 218(3.6%) had their surveys returned by the postal service

due to a wrong address, 49 (0.8%) lived in a US terri-tory, and 5 (0.1%) were reported as deceased. Of the4934eligible individuals, 2441 responded, for a final re-sponse rateof 49.5%. Of the 2518 eligible physicians whoreceived the survey addressing reimbursement reform,there were 1222 respondents (response rate, 48.5%).There were no significant differences between respon-dents and nonrespondents regarding age, sex, specialtygroup, geographic region, and office-based practice set-ting (Table 1).

PARTICIPANT CHARACTERISTICS

Themeanageofthesamplewas51.6years,73.1%weremen,and77.2%practicedin office-basedsettings.More thanhalfoftherespondentswerepracticeownersorpartners(58.4%),andmostreportedacceptingMedicare(82.0%);39%receivedperformance bonuses in addition to their salary.

CURRENT OPINIONON MEDICARE REIMBURSEMENTS

Most physicians (78.4%) indicated that Medicare reim-bursements are inequitable. There was little differencein attitude about the equitability of Medicare reimburse-ment across physician specialties (P =.07) (Figure 1).Of physicians who accepted Medicare, 40.2% stronglyagreed and 38.2% somewhat agreed that under Medi-care, some procedures are compensated too highly andothers are compensated at rates insufficient to cover costs.Only 11.5% of physicians disagreed with the statement,and 10.2% were unsure. There were no significant dif-

ferences in opinion regarding Medicare reimbursementacross any of the physician variables (data not shown).

SUPPORT FOR PROPOSALS TO REFORMPHYSICIAN REIMBURSEMENT

Of the 3 reimbursement reform proposals, physiciansshowed the highest level of support for the use of incen-tives to improve quality, with approximately half (49.1%)strongly or somewhat supporting this approach. Sup-port for incentive-based reform was similar across phy-

Table 1. Characteristics of Respondentsand Nonrespondentsa

VariableRespondents

(n=1222)Nonrespondents

(n=1296)P

Value

Age, mean (SD), y 51.6 (11.9) 50.9 (12.0) .82

Male sex, % 73.1 71.5 .39

Specialty, %

.78

General practice 26.7 26.8

Medical subspecialty 24.6 25.8

Surgery 24.2 24.5

Other 24.6 22.9

Census region, %

.20

West 21.2 23.0

Midwest 20.5 21.5

South 35.6 31.6

Northeast 22.8 24.0

Census division, %

.15

Pacific 14.7 17.4

Mountain 6.5 5.6

West North Central 6.6 5.3

West South Central 10.3 9.4

East North Central 13.8 16.2

East South Central 5.0 4.7

South Atlantic 20.3 17.4

Middle Atlantic 16.6 17.7

New England 6.1 6.2Urban practice location, % 91.0 91.7 .55

Office-based practice, % 77.2 75.5 .31

Practice ownerb 58.4 NA NA

Patient care20 h, wkb 84.5 NA NA

Insurance/paymentaccepted, %b

NA

Medicare 82.0 NA

Medicaid 73.5 NA

Private 88.0 NA

Cash 86.5 NA

Other 18.4 NA

Not applicable 7.3 NA

Source of income, %b

NA

Salary only 26.2 NA

Salarybonus 39.0 NA

Billing only 18.9 NAShift work/hourly wages 5.3 NA

Other 10.6 NA

Abbreviation: NA, not available.a Values are based on unweighted data.b These variables were not available in the American Medical Association

Physician Masterfile.

100

90

80

70

60

50

40

30

1020

0Generalists Medical

SpecialistsSurgeons Other

Specialties

Specialty Group

Physicians,

%

Agree Unsure Disagree

Figure 1.Agreement with the statement that Medicare reimbursement isinequitable by specialty group.





4/8

sician specialties, geographic locations of the practices,practice types, practice ownership, and the physiciansmode of compensation (Table 2).

Overall, 41.6% of physicians supported shifting pay-ments and46.4%opposed it.Most generalists (66.5%) sup-porteda shift inreimbursement towardcounselingandman-agement compared with only 16.6% of surgeons (P .001for the difference across the 4 specialty groups). In addi-

tion, support for shifting paymentswas less likely to be ex-pressed by physiciansin office-basedpracticesettings,prac-tice owners, and those with fewer patient care hours.

Most physicians viewed bundling of payments unfa-vorably, with 69.1% of physicians opposing it. Supportfor bundling payments was low across all physician char-acteristics, with lower levelsof support expressed by office-based practitioners, practice owners, and physicians see-ing patients more than 20 hours per week.

In unadjusted regression analysis, surgeons, medicalsubspecialists, and other physicians were markedly less

supportive of shifting payments to generalists than weregeneralists themselves (Table 3). These associations werenot appreciably altered by adjusting for practice charac-teristics and census division. Nongeneralists were alsoless supportive of incentives and bundling than were gen-eralists, although the differences generally were not sta-tistically significant (Table 3). Practice owners were lesssupportive of shifting payments (adjusted odds ratio[AOR], 0.72; 95% confidence interval [CI], 0.52-0.99)and bundling (AOR, 0.53; 95% CI, 0.38-0.76) than werenonowners. Physicians who provided more than 20 hoursof patient care per week were similarly less supportiveof shifting payments (AOR, 0.59; 95% CI, 0.40-0.88) andof bundling (AOR, 0.56; 95% CI, 0.37-0.85).

SUPPORT FOR INCREASING PAYFOR GENERALISTS

There was broad support for increasing pay for general-ists: 79.8% of respondents expressed support and only13.3% were opposed (Figure 2). Even among sur-geons, three-quarters (76.6%) supported increased pay-ments for generalists (Table 4). In contrast to support

for the other reimbursement reform proposals,only17.2%of physicians supported bundling. Fewer than half of thephysicians (39.1%) supported such a strategy, and theleast support was expressed by surgeons (21.7%).

Although there was broad support for increasing payfor generalists, physicians in the nongeneralist special-ties were considerably less supportive of this strategy, inunadjusted and unadjusted analyses, and even less sowhen there was a cost offset (Table 5).

COMMENT

In this national survey, we found that most physiciansbelievethatMedicare reimbursements are inequitable, andyet there was little consensus on strategies to reform pay-ment. Physicians generally showed the least support forproposals that carried the risk of reduced reimburse-ment, such as payments for bundled care. For physi-cians who frequently perform procedures, such as sur-geons, there was low support for shifting somereimbursement from procedures to evaluation and man-agement services, and there was very low support amongsurgeons and other nonmedical specialists for a 3% re-duction in reimbursements to offset increased pay-ments for primary care physicians.

Morethanthree-quartersof the physicians indicatedthatMedicare reimbursements are inequitable, a finding that

was constant across physician specialties, practice set-tings, and practice ownership. This observation is consis-tent with previously published findings that physiciansbe-lieve that timeliness and adequacy of reimbursements isbetter under private insurers than it is under Medicare.24

They also echo the call for changes in Medicares rate-setting policies.8,25,26 The Centers for Medicare and Med-icaid Services establishes payment rates for physician ser-vices using a resource-based relative value scale but alsoreceives adviceon settingreimbursement rates fromthe Spe-cialty Society Relative Value Scale Update Committee

Table 2. Characteristics of 1222 Physicians Who SupportSpecific Payment Reform Proposalsa

Variable

Physicians Who Support, %

Incentives bShifting

Payments c Bundlingd

Specialty

General practice 52.7 66.5e 21.3

Medical subspecialty 45.4 54.0 16.0

Surgery 47.0 16.6 15.2Other 52.2 27.3 16.0

Census division

Pacific 55.2 52.0 22.8 f

Mountain 49.1 49.5 16.8

West North Central 45.5 48.5 14.0

West South Central 41.8 45.3 8.6

East North Central 50.5 46.2 26.6

East South Central 56.7 42.8 16.6

South Atlantic 50.4 42.9 14.5

Middle Atlantic 49.9 49.2 16.1

New England 38.3 59.2 22.4

Practice setting

Office based 47.5 45.9e 15.7e

Other 55.3 54.3 25.1

Practice owner

Yes 46.7 42.6e 13.3eNo 53.0 55.0 24.0

Patient care, h/wk20 51.9 f 45.4e 29.7e

20 48.8 61.1 15.8

Source of income

Salary only 53.6 51.2 20.0 f

Salarybonus 52.3 41.8 18.8

Billing only 45.6 53.4 14.6

Shift work/hourly wages 43.0 45.8 14.6

Other 38.3 50.4 12.9

a Weighted 2 test.b Incentivesindicates paying physicians a higher rate for higher-quality

care (bonus) and a lower rate for lower-quality care (penalty).c Shifting Paymentsindicates increasing payments for management and

counseling while decreasing payments for procedures.d Bundlingindicates paying physicians a fixed amount for all services

associated with an episode of care.e P .001.f P .05.





5/8

(RUC), which is composed of representatives of medicalspecialties. The RUC has drawn criticism for overestimat-ing the relative resource needs of physicians in specific spe-cialties and for specific procedures.26,27 Physician dissatis-factionwithMedicarereimbursements24 andconcernsaboutequity of reimbursements suggest that the role of the RUCin advising Medicare should be carefully evaluated. TheObama administration andhealth policy experts havecalledfor the creationof an independentMedicare advisory com-

mittee.

28

However, only 1 Congressional health care re-form proposal included an independent Medicare com-mission.29Withoutan independentarbiter,physicians andphysician groups are likely to continue having complaintsabout the equitability of reimbursements under Medicare.

There was little unity regarding support for physi-cian payment reform proposals. Half of the physicianssupported financial incentives to improve quality. Sup-port for incentives was more common and more consis-tent acrossallspecialtiescompared with shifting and bun-dling payments. Actual experience with financial

incentives to improve quality could have directly in-formed physicians generally more positive views of thesetypes of reimbursement mechanisms. For example, higherapproval of incentives may reflect the fact that incen-tives are already widely applied in outpatient care, suchas in managed care organizations or in the Medicare Phy-sician Quality Reporting Initiative.30

There was even less consensus among physicians re-garding shifting some portion of payments from proce-

dures to management and counseling. As expected, thosewho conduct procedures were against it, and those whodo more management and counseling were for it. Nev-ertheless, some surgeons (17%) and physicians in otherprocedurally oriented specialties (27%) supported shift-ing payments toward evaluation and management ser-vices, indicating that underpayment of management andcounseling even in procedurally oriented specialties is aconcern for many physicians.

Most physicians from all specialties were opposed tobundled payments (69%). Surgeons, who may have the

Table 3. Adjusted and Unadjusted Weighted Analyses of Support for Payment Reform Proposals

Variable

Support, OR (95% CI)

Incentives a Shifting Paymentsb Bundlingc

Unadjusted Adjustedd Unadjusted Adjustedd Unadjusted Adjustedd

Specialty

General practice 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]

Medical subspecialty 0.77 (0.57-1.04) 0.72 (0.53-0.99)e 0.57 (0.42-0.78) f 0.51 (0.37-0.71) f 0.75 (0.51-1.10) 0.70 (0.45-1.03)

Surgery 0.73 (0.54-0.99)e

0.73 (0.53-1.01) 0.10 (0.07-0.14)f

0.09 (0.06-0.13)f

0.65 (0.44-0.97)e

0.68 (0.44-1.05)Other 0.91 (0.68-1.24) 0.87 (0.63-1.19) 0.18 (0.13-0.25) f 0.16 (0.11-0.23) f 0.70 (0.47-1.03) 0.68 (0.45-1.02)

Census division

Pacific 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]

Mountain 0.69 (0.40-1.18) 0.68 (0.39-1.17) 1.02 (0.60-1.74) 0.91 (0.50-1.67) 0.72 (0.36-1.43) 0.78 (0.38-1.59)

West North Central 0.70 (0.41-1.18) 0.64 (0.37-1.10) 0.96 (0.57-1.62) 0.94 (0.50-1.79) 0.63 (0.31-1.27) 0.59 (0.29-1.21)

West South Central 0.55 (0.34-0.88) f 0.52 (0.32-0.84) f 0.77 (0.48-1.24) 0.65 (0.38-1.09) 0.28 (0.13-0.60)g 0.30 (0.14-0.63)f

East North Central 0.77 (0.51-1.19) 0.72 (0.46-1.11) 0.93 (0.61-1.43) 0.74 (0.46-1.19) 1.07 (0.65-1.77) 1.03 (0.60-1.75)

East South Central 0.87 (0.48-1.55) 0.87 (0.48-1.58) 0.71 (0.39-1.28) 0.61 (0.32-1.16) 0.77 (0.37-1.60) 0.81 (0.38-1.72)

South Atlantic 0.74 (0.50-1.10) 0.71 (0.47-1.07) 0.76 (0.51-1.12) 0.60 (0.38-0.94) f 0.57 (0.34-0.94)e 0.54 (0.31-0.91)e

Middle Atlantic 0.71 (0.47-1.08) 0.71 (0.46-1.09) 0.88 (0.58-1.33) 0.66 (0.41-1.05) 0.59 (0.35-1.00)e 0.53 (0.30-0.94)e

New England 0.50 (0.29-0.88)e 0.44 (0.25-0.77) f 1.26 (0.73-2.18) 1.00 (0.55-1.82) 1.04 (0.55-2.00) 0.90 (0.56-1.76)

Office-based practice

Yes 0.76 (0.59-0.98)e 0.88 (0.66-1.17) 0.77 (0.60-0.99)e 0.87 (0.63-1.19) 0.61 (0.44-0.83)f 0.78 (0.55-1.11)

No 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]

Practice owner

Yes 0.72 (0.60-0.95)e

0.85 (0.64-1.13) 0.61 (0.48-0.77)f

0.72 (0.52-0.99)e

0.47 (0.34-0.64)f

0.53 (0.38-0.76)f


Patient care, 20 h/wk

Yes 0.89 (0.65-1.24) 0.92 (0.64-1.30) 0.53 (0.39-0.74)g 0.59 (0.40-0.88) f 0.47 (0.33-0.69) 0.56 (0.37-0.85)f


Source of income

Salary only 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]

Salarybonus 0.88 (0.66-1.16) 0.96 (0.70-1.31) 0.67 (0.50-0.89)f 0.84 (0.59-1.19) 0.93 (0.65-1.33) 1.18 (0.80-1.73)

Billing only 0.71 (0.51-1.01) 0.80 (0.54-1.18) 1.08 (0.77-1.53) 1.54 (0.99-2.41) 0.70 (0.44-1.13) 1.04 (0.62-1.74)

Shift work/hourly wages 0.67 (0.38-1.17) 0.69 (0.39-1.24) 0.75 (0.43-1.32) 0.53 (0.27-1.02) 0.65 (0.30-1.40) 0.62 (0.28-1.39)

Other 0.50 (0.32-0.76) f 0.54 (0.35-0.86) f 0.94 (0.62-1.42) 1.11 (0.68-1.81) 0.66 (0.37-1.18) 0.74 (0.40-1.36)

Abbreviations: CI, confidence interval; OR, odds ratio.a Incentivesindicates paying physicians a higher rate for higher-quality care (bonus) and a lower rate for lower-quality care (penalty).b Shifting Paymentsindicates increasing payments for management and counseling while decreasing payments for procedures.c Bundlingindicates paying physicians a fixed amount for all services associated with an episode of care.d Adjusted for all the independent variables listed in column 1.e P .05.f P .01.g P .001.





6/8

most experience with bundling,31 expressed the lowestlevels of support for this strategy. With bundling, phy-sicians and health care systems are at greater financialrisk, and uncertainty remains about who would have re-sponsibility for controlling costs and how savings gen-erated through greater efficiency in health care provi-sion and better health outcomes would be divided amongentities sharing in thecareofa patient.31,32 Because bundledpayments are likely to be implemented in one form oranother,1,2 this mechanism ought to be carefully ex-plained to physicians to promote broad acceptance andsmooth implementation. Research that further charac-terizes physicians experience with and concerns aboutbundling could provide guidance toward these ends. Ofnote, physicians in the West South Central census divi-sion of the United States were less likely to support in-centives or bundled payments. Additional research mighthelp determine which factors contribute to this regionalvariation in views on payment reform.

Reducing the fragmented provision of care throughimprovements in care coordination and continuity of caremay be necessary before bundling, and other strategiescould successfully contribute to improvedhealth care andcost savings.7,31 To improve care coordination and in-crease the delivery of preventive care and counselingser-vices, several reform plans have proposed increasing re-imbursement to generalist physicians, an idea supportedby most physicians surveyed in this study. Surgeons andother specialists, however, were considerably less sup-portive when the proposal calledfor shifting some of theirreimbursement to meet the costs of increased payments

to generalists, a strategy proposed for Medicare by theSenate Finance Committee.7

This study is limitedby a 48.5% responserate. This rateis slightly lower than the average for physician surveys33;however, there were no differences between respondentsand nonrespondents on important characteristics. Fur-thermore, we collected data during just 4 months, a briefperiod intended to capture physician views near the apexof thehealthcare reformdebate.Although physicians opin-ions about strategies for expanding health insurance cov-erage may have evolved across time, we found no signifi-

cant differences between opinions expressed in surveysreceived at different time points during the period of datacollection. Finally, duringthe period of data collection, pro-posals for reimbursement reform were in flux as Congresstried to work out legislation. For example, the Senate Fi-nance Committee proposed a 10% Medicare payment bo-nus for primary care providers with half of the cost of thebonuses offsetby a 0.5% reduction in allother services.Thetradeoff we used in the present study was a 3% reduction

in reimbursementsfor nonprimary care physicians. Phy-siciansrespondingto thissurveymighthavebeen more ame-nable to a lower reduction in reimbursement, such as wasproposed by the Senate Finance Committee.7 The PatientProtection and Accountable Care Act did include a pay-ment bonus for primary care but no reductionin paymentfor other services.

In conclusion, most physicians believe thatMedicare re-imbursements are inequitable, yet there is little consensusamong them regarding major proposals to reform reim-bursement. Bundling of payments, in particular, was op-

100

75

25

50

0Increase Pay for

Primary Care

79.8

7.0

13.3

39.1

9.8

51.1

Decrease Pay to Specialistsby 3% to Increase Pay

for Primary Care

Respondents,

%

Support

Unsure

Oppose

Figure 2.Rates of support for increased pay for primary care physicians(n=1222). Due to rounding, the percentages for the increased pay section donot total 100.

Table 4. Characteristics of 1222 Physicians Who SupportIncreasing Pay for Primary Care a

Variable

Support Increasing Payfor Primary Care, %

Without Changein Specialist

Reimbursement

With a 3% Reductionin Specialist

Reimbursement

Specialty

General practice 88.3b 63.0bMedical subspecialty 72.6 36.7

Surgery 76.6 21.7

Other 81.0 33.7

Census division

Pacific 82.4 45.9

Mountain 75.7 43.6

West North Central 77.5 45.4

West South Central 77.0 42.3

East North Central 80.1 41.9

East South Central 82.4 41.5

South Atlantic 79.6 37.2

Middle Atlantic 81.4 43.4

New England 86.1 52.2

Practice location

Urban 76.1 41.7

Rural 80.7 53.6Practice setting

Office based 79.9 40.7c

Hospital/other 81.6 50.1

Practice owner

Yes 79.1 37.8b

No 82.0 50.5

Patient care, h/wk

20 81.6 51.7c

20 80.0 41.3

Source of income

Salary only 80.7 47.2

Salarybonus 81.4 39.6

Billing only 79.4 45.9

Shift work/hourly wages 80.3 41.9

Other 76.4 38.9

a Weighted 2 test.bP .001.c P .05.





7/8

posed by most physicians. Overall, physicians seem to beopposed to reformsthatrisk lowering their incomes. Thus,finding common ground among different specialties to re-form physician reimbursement, reduce health care spend-ing, and improve health care quality will be difficult. Re-search thatclarifiesthetradeoffs physicianswould bewillingto accept in paymentreform, and otherconcerns, may helprefine the design of payment reforms and improve accep-tance among physicians.

Accepted for Publication:March 14, 2010.

Correspondence:Alex D. Federman, MD, MPH, Divi-sion of General Internal Medicine, Mount Sinai Schoolof Medicine, PO Box 1087, One Gustave L. Levy Place,New York, NY 10029 ([email protected]).Author Contributions: Dr Federman had full access to allthe data in the study andtakes responsibility for the integ-rity of the data and the accuracy of the data analysis. Studyconcept and design:Federman, Woodward, and Keyhani.Acquisition of data:Federman and Keyhani.Analysis andinterpretation of data: Federman, Woodward, and Key-hani.Drafting of the manuscript: Federman and Keyhani.

Critical revision of the manuscript for important intellectualcontent: Federman, Woodward, and Keyhani.Statisticalanalysis: Federman, Woodward, and Keyhani.Obtainedfunding: Federman and Keyhani.Administrative, technical,and material support:Federman and Keyhani.Financial Disclosure:None reported.Funding/Support: This project was supported by a grantfrom the Robert Wood Johnson Foundation and also bygrants from the National Institute on Aging; the Na-tional Heart, Lung, and Blood Institute; and the Veter-ans Administration Health Services Research and Devel-

opment Service (Drs Federman and Keyhani).Role of the Sponsors: The Robert Wood Johnson Foun-dation played no role in thedesign or conduct of thestudy;in the collection, management, analysis, or interpreta-tion of the data; or in the preparation, review, or ap-proval of the manuscript.Online-Only Material: An eAppendix is available at http://www.archinternmed.com.Additional Contributions:Helen Cole, MPH, providedproject management, and Cathy Schoen, PhD; KennethShine, MD; Gerard Anderson, PhD; Thomas Russell, MD;

Table 5. Adjusted and Unadjusted Weighted Analyses of Support for Increasing Pay for Primary Care

Variable

Support Increasing Pay for Primary Care, OR (95% CI)

Without Changein Specialist Reimbursement

With a 3% Reductionin Specialist Reimbursement

Unadjusted Adjusteda Unadjusted Adjusteda

Specialty

General practice 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]

Medical subspecial ty 0.38 (0.25-0.57)b

0.37 (0.24-0.57)b

0.33 (0.24-0.46)b

0.31 (0.22-0.43)b

Surgery 0.43 (0.28-0.65)b 0.43 (0.28-0.66)b 0.16 (0.11-0.22)b 0.16 (0.11-0.22)b

Other 0.53 (0.35-0.82)c 0.52 (0.33-0.80)c 0.29 (0.21-0.39)b 0.27 (0.19-0.38)b

Census division

Pacific 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]

Mountain 0.67 (0.35-1.26) 0.62 (0.32-1.17) 0.96 (0.56-1.64) 0.85 (0.47-1.56)

West North Central 0.74 (0.39-1.42) 0.75 (0.38-1.47) 0.92 (0.54-1.58) 0.90 (0.49-1.64)

West South Central 0.77 (0.43-1.37) 0.73 (0.41-1.31) 0.79 (0.49-1.28) 0.68 (0.41-1.11)

East North Central 0.98 (0.57-1.69) 0.90 (0.51-1.57) 0.99 (0.65-1.52) 0.81 (0.50-1.30)

East South Central 1.11 (0.53-2.32) 1.00 (0.48-2.08) 0.77 (0.42-1.39) 0.67 (0.36-1.24)

South Atlantic 0.82 (0.50-1.34) 0.77 (0.46-1.30) 0.76 (0.51-1.14) 0.64 (0.41-1.01)

Middle Atlantic 0.96 (0.57-1.63) 0.94 (0.54-1.64) 0.86 (0.57-1.31) 0.72 (0.44-1.16)

New England 1.40 (0.65-3.02) 1.38 (0.62-3.05) 1.31 (0.77-2.26) 1.09 (0.63-1.89)

Office-based practice

Yes 0.79 (0.57-1.09) 0.79 (0.54-1.15) 0.71 (0.55-0.91)c 0.82 (0.60-1.11)

No 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]

Practice ownerYes 0.84 (0.63-1.13) 0.94 (0.65-1.35) 0.60 (0.47-0.76)b 0.70 (0.51-0.95)d


Patient care, 20 h/wk

Yes 1.02 (0.68-1.53) 1.01 (0.65-1.56) 0.68 (0.49-0.94)d 0.74 (0.51-1.09)


Source of income

Salary only 1 [Reference] 1 [Reference] 1 [Reference] 1 [Reference]

Salarybonus 1.01 (0.71-1.45) 1.14 (0.76-1.71) 0.72 (0.54-0.96)d 0.87 (0.62-1.22)

Billing only 0.88 (0.57-1.35) 1.03 (0.62-1.69) 0.90 (0.64-1.28) 1.24 (0.80-1.91)

Shift work/hourly wages 0.96 (0.47-1.96) 1.05 (0.51-2.15) 0.74 (0.42-1.30) 0.67 (0.36-1.27)

Other 0.71 (0.43-1.16) 0.72 (0.41-1.24) 0.67 (0.44-1.04) 0.78 (0.48-1.27)

Abbreviations: CI, confidence interval; OR, odds ratio.a Adjusted for all the independent variables listed in column 1.b P .001.c P .01.d P .05.





8/8

ShoshannaSofaer, DrPH; andLawrence Brown,PhD, pro-vided helpful comments in developing this study.

REFERENCES

1. Luft HS. Health care reformtoward more freedom, and responsibility, for

physicians.N Engl J Med. 2009;361(6):623-628.

2. Fisher ES, Bynum JP, Skinner JS. Slowing the growth of health care costs

lessons from regional variation.N Engl J Med. 2009;360(9):849-852.

3. HenryJ Kaiser Family Foundation. HealthCareCosts: A Primer: KeyInformation

on Health Care Costs and Their Impact.Menlo Park, CA: Henry J Kaiser FamilyFoundation; 2009. http://www.kff.org/insurance/upload/7670_02.pdf. Ac-

cessed March 1, 2009.

4. Bodenheimer T. High and rising health care costs: part 3: the role of health care

providers.Ann Intern Med. 2005;142(12, pt 1):996-1002.

5. Rother J. A consumer perspective on physician payment reform.Health Aff

(Millwood). 2009;28(2):w235-w237.

6. Kautter J, PopeGC, Trisolini M, Grund S. Medicarephysiciangroup practicedem-

onstration design: quality and efficiency pay-for-performance. Health Care Fi-

nanc Rev. 2007;29(1):15-29.

7. Senate Finance Committee.Framework for Comprehensive Health Reform. US

Senate; September 8, 2009.

8. Milgate K, Cheng SB. Pay-for-performance: the MedPAC perspective.Health Aff

(Millwood). 2006;25(2):413-419.

9. AntosJ,BertkoJ, ChernewM, etal. Bendingthe curve: effectivestepsto addresslong-

term healthcare spending growth.AmJ ManagCare. 2009;15(10):676-680.

10. Mechanic RE, Altman SH. Payment reform options: episode payment is a good

place to start.Health Aff (Millwood). 2009;28(2):w262-w271.11. Guterman S, Davis K, Schoenbaum S, Shih A. Using Medicare payment policy

to transform the health system: a framework for improvingperformance. Health

Aff (Millwood). 2009;28(2):w238-w250.

12. Henry J. Focus on Health Reform: Summary of new health reform law. http:

//www.kff.org/healthreform/upload/8061.pdf. Accessed August 13, 2010.

13. Federal Register. http://edocket.access.gpo.gov/2010/pdf/2010-15900.pdf. Ac-

cessed August 13, 2010.

14. Barr M, Ginsberg J.The Advanced Medical Home: Patient-Centered, Physician-

Guided Care for the Chronically Ill. Philadelphia, PA: American College of Phy-

sicians; 2006.

15. McCormick D, Woolhandler S, Bose-Kolanu A, Germann A, Bor DH, Himmel-

steinDUUS. U.S.physicians viewson financingoptions to expand health insur-

ance coverage: a national survey. J Gen Intern Med. 2009;24(4):526-531.

16. Fink A, Kosecoff J, Chassin M, Brook RH. Consensus methods: characteristics

and guidelines for use.Am J Public Health. 1984;74(9):979-983.

17. Ackermann RT, Carroll AE. Support for national health insurance among U.S.

physicians: a national survey.Ann Intern Med. 2003;139(10):795-801.

18. CasalinoLP, AlexanderGC, JinL, Konetzka RT.Generalinternistsviews onpay-

for-performance and public reportingof quality scores: a national survey. Health

Aff (Millwood). 2007;26(2):492-499.

19. Freed GL, Cowan AE, Clark SJ. Primary care physician perspectives on reim-

bursement for childhood immunizations. Pediatrics. 2008;122(6):1319-

1324.

20. McCormick D, Himmelstein DU, Woolhandler S, Bor DH. Single-payer national

health insurance: physicians views.Arch Intern Med. 2004;164(3):300-

304.

21. McMahonSR, Iwamoto M, MassoudiMS, et al.Comparisonof e-mail,fax, andpostal

surveysof pediatricians. Pediatrics. 2003;111(4, pt 1):e299-e303.http://pediatrics

.aappublications.org/cgi/content/full/111/4/e299. Accessed August 25,

2010.

22. Meier DE, Emmons CA, Wallenstein S, Quill T, Morrison RS, Cassel CK. A na-

tional survey of physician-assisted suicide and euthanasia in the United States.

N Engl J Med. 1998;338(17):1193-1201.

23. American Association for Public Opinion Research.Standard Definitions: Final

Dispositionsof CaseCodesand Outcome Rates for Surveys.Deerfield, IL:Ameri-

can Association for Public Opinion Research; 2006.

24. Keyhani S, Federman A. Physician Views on the Public Health Insurance Option

and MedicareExpansions.Princeton, NJ: RobertWood JohnsonFoundation;Sep-

tember 2009.

25. Ginsburg PB, Berenson RA. Revising Medicares physician fee schedule

much activity, little change.N Engl J Med. 2007;356(12):1201-1203.

26. Bodenheimer T, Berenson RA, Rudolf P. The primary care-specialty income gap:

why it matters.Ann Intern Med. 2007;146(4):301-306.

27. Rich WL III. The primary care-specialty income gap.Ann Intern Med. 2007;146

(12):895-896, author reply 896.

28. Pham HH, Ginsburg PB, Verdier JM. Medicare governance and provider pay-ment policy.Health Aff (Millwood). 2009;28(5):1382-1394.

29. Congressional Budget Office analysis of the Americas Healthy Future Act as

amended. http://finance.senate.gov/issue/?id=82dd713a-cc17-425a

-a3ef-f05518995956. Accessed October 10, 2009.

30. Centers for Medicare and Medicaid Services.Physician Quality Reporting Initia-

tive:2007 ReportingExperience. Baltimore,MD: Centers for Medicare and Med-

icaid Services; December 3, 2008.

31. Miller HD. From volume to value: better ways to pay for health care.Health Aff

(Millwood). 2009;28(5):1418-1428.

32. The Commonwealth Fund. MEDPAC probes effectiveness of accountable care

organizations. http://www.commonwealthfund.org/Content/Newsletters

/ Wa sh in g t on -H ea lt h- Po li c y- in - Re v ie w/ 20 09 / A pr / Ap r il - 20 - 20 0 9

/MEDPAC-Probes-Effectiveness-of-Accountable-Care-Organizations.aspx. Ac-

cessed October 11, 2009.

33. Asch DA, Jedrziewski MK, Christakis NA. Response rates to mail surveys pub-

lished in medical journals.J Clin Epidemiol. 1997;50(10):1129-1136.

INVITED COMMENTARY

Reforming Payment for Health Care Services

American medicine has long been characterizedby fee-for-service (FFS) payment. The FFSsystem has several merits. It rewards hard

work and productivity and incentivizes physicians notto stint on care. It avoids placing physicians at finan-cial risk if they care for sick patients and facilitatesfinancing systems that allow patients unconstrainedchoice of provider (eg, physicians, allied health profes-sionals, and hospitals).

Yet the FFS system has come under attack lately asa primary contributor to the ills of the American

health care system. A drawback of the FFS systemsincentive not to stint on care is an incentive to overusecare. While physicians are unlikely to intentionally

provide care that is unneeded or even harmful,payment rates in most existing FFS systems are highenough to remove the incentives to eliminate suchcare. Moreover, FFS systems can facilitate growth of a

See also page 1728



Documents

Federman - Physicians' Opinions About Reforming Reimbursement