More than $100-million in bonuses the Ontario government paid to doctors did little to increase screening rates for three kinds of cancer, according to a new study that undermines the popular notion that financial incentives can change how physicians care for their patients.
Researchers at the Institute for Clinical Evaluative Sciences and St. Michael's Hospital in Toronto found a program introduced in 2006 produced no significant change, despite the province spending $28.3-million, $31.3-million and $50-million, respectively, on bonuses over three years for family doctors who hit targets for cervical, breast and colorectal cancer screening.
"We all know it's tight financial times," said Tara Kiran, a family doctor and researcher at St. Michael's and co-author of the paper, published Monday in Annals of Family Medicine. "So is this really the best value for our money?"
The new study comes as pay-for-performance schemes for physicians are falling under increasing scrutiny, especially in Quebec, where Liberal cabinet minister Yves Bolduc has been chastised for collecting $215,000 in bonus payments for enrolling new patients in a medical practice he kept on the side while sitting in opposition.
The pay-for-performance approach is used in different ways and to different degrees in other provinces too.
In British Columbia, for instance, incentive payments for doctors accounted for about $700-million of a $1-billion primary-care reform effort. Despite the bonuses, access to family doctors in B.C. actually decreased over 20 years, according to a study published in the May edition of the journal Healthcare Policy.
The new Ontario paper is part of a growing body of research casting doubt on bonus pay for doctors, said Noah Ivers, a family physician and scientist at Women's College Hospital in Toronto who was not involved in the study.
"[Pay for performance] only makes sense if motivation is the problem and I don't think it is," he said. "When it comes to cancer screening, all the providers are on the same page, everybody wants to get cancer screening done."
The Ontario Health Insurance Program, or OHIP, already pays doctors a standard fee for every screening test they perform. The bonuses came on top of that.
In the case of cervical cancer, for instance, doctors received a bonus of $220 a year if 60 per cent of their female patients ages 35 to 69 (excluding women who had undergone hysterectomy) received a pap smear in the past 30 months. If 80 per cent of patients were screened, the bonus grew to $2,200 a year. Doctors who surpassed the 80-per-cent screening goal for all three cancers earned an additional $8,400 a year.
During the study period, the age-adjusted screening rate increased from 55 per cent to 57 per cent for cervical cancer, 60 to 63 per cent for breast cancer, and 20 to 51 per cent for colorectal.
Although the increase in colorectal cancer screening appears significant, Dr. Kiran said the rate was already increasing 3 per cent a year before the introduction of the bonuses, a figure that grew to 4.7 per cent afterward – but not right away. She pointed out that a massive provincewide media campaign promoting colorectal cancer screening was launched in 2008.
The Ontario Medical Association, which represents the province's doctors, said it was good news that rates were up slightly.
"As a cancer surgeon myself, I can tell you that doctors screen patients to save lives," Ved Tandan, president of the OMA, said in an e-mailed statement. "At first glance we were pleased to see an increase in screening for breast and colorectal cancers and look forward to reviewing the report in more detail."
A spokeswoman for the Ontario Ministry of Health and Long-Term Care said bonuses are negotiated with the Ontario Medical Association. "The ministry will work collaboratively with the OMA to examine the incentive structures within primary care models to achieve the desired goal of improving health outcomes." The province and doctors are currently negotiating a new contract; the doctors' last deal expired at the end of March.
There are a few possible reasons the bonuses had scant impact, Dr. Kiran said.
They were limited to family doctors who formally enroll patients in their practices, meaning doctors who work at walk-in clinics were excluded.
Screening rates among primary-care physicians with formal enrolment policies already tend to be high, Dr. Kiran said. If a physician was already meeting the 80-per-cent target before the bonuses were introduced, he or she could receive the maximum payout without contributing to a change in the overall rates.
The maximum bonuses worked out to only about 3 per cent of physicians' gross income, an amount that was perhaps too small to spur significant change, the study suggested.
The study also showed that patients from poor neighbourhoods were less likely to get screened.