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Physician Variation and the Impact of Payment Model in Cardiac Imaging
Amity E Quinn1,2, Derek S Chew1,3,2, Peter Faris2,4
1Department of Medicine, Cumming School of Medicine University of Calgary Alberta Canada.
Insights
Physician payment models significantly impact cardiac imaging use in patients with heart disease. Fee-for-service reimbursement, especially with interpretation billing, led to more imaging tests compared to salaried models.
Area of Science:
- Cardiology
- Health Services Research
- Health Economics
Background:
- Fee-for-service reimbursement's effect on cardiac imaging remains unexamined compared to other payment models.
- Understanding variation in cardiac imaging ordering practices is limited.
Purpose of the Study:
- To compare the influence of fee-for-service reimbursement versus other payment models on cardiac imaging utilization.
- To quantify variation in cardiac imaging use and identify contributing factors.
Main Methods:
- Retrospective, population-based cohort study using linked administrative data from Alberta, Canada (April 2012-December 2018).
- Included adults with chronic heart disease (atrial fibrillation, coronary artery disease, heart failure) consulting cardiac specialists.
- Generalized linear mixed-effects models analyzed the association between physician payment models and cardiac imaging use, controlling for patient, physician, and site factors.
Main Results:
- Patients consulting fee-for-service physicians were 2.07 times more likely to receive cardiac imaging.
- Fee-for-service physicians with interpretation billing capability showed an even higher rate (2.87 times).
- Patient, physician, and site factors explained 31% of imaging variation, reducing unexplained site and physician-level variation by 40% and 29%, respectively.
Conclusions:
- Substantial variation exists in outpatient cardiac imaging use, influenced by physician and site characteristics.
- Physician payment models are significantly associated with imaging utilization, raising concerns about potential practice influence.
- The methodology can be applied to investigate variations in other healthcare processes and outcomes.
Background:
The influence of fee-for-service reimbursement on cardiac imaging has not been compared with other payment models. Furthermore, variation in ordering practices is not well understood.
Methods And Results:
This retrospective, population-based cohort study using linked administrative data from Alberta, Canada included adults with chronic heart disease (atrial fibrillation, coronary artery disease, and heart failure) seen by cardiac specialists for a new outpatient consultation April 2012 to December 2018. Generalized linear mixed-effects models estimated the association of payment model (including the ability to bill to interpret imaging tests) and the use of cardiac imaging and quantified variation in cardiac imaging. Among 31 685 adults seen by 308 physicians at 136 sites, patients received an observed mean of 0.67 (95% CI, 0.67-0.68) imaging tests per consultation. After adjustment, patients seeing fee-for-service physicians had 2.07 (95% CI, 1.68-2.54) and fee-for-service physicians with ability to interpret had 2.87 (95% CI, 2.16-3.81) times the rate of receiving a test than those seeing salaried physicians. Measured patient, physician, and site effects accounted for 31% of imaging variation and, following adjustment, reduced unexplained site-level variation 40% and physician-level variation 29%.
Conclusions:
We identified substantial variation in the use of outpatient cardiac imaging related to physician and site factors. Physician payment models have a significant association with imaging use. Our results raise concern that payment models may influence cardiac imaging practice. Similar methods could be applied to identify the source and magnitude of variation in other health care processes and outcomes.
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