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Cash Incentives Fail to Improve Care for Complex Patients

Paying primary care physicians a $315 per-complex-patient annual fee did not improve care, decrease hospitalizations, or save costs in British Columbia, according to a study in the  Canadian Medical Association Journal.

Researchers came to their findings after comparing data for 155,754 patients who qualified for the Complex Care Initiative incentive fee code for having 2 or more chronic conditions, such as heart disease, diabetes, and kidney disease. The study looked at patients’ primary care contacts, hospitalizations, and costs, among other factors, for the 2 years before and 2 years after the initiative’s launch in 2007. Nearly 64% of eligible patients had at least 1 incentive payment billed.

“After accounting for secular trends, we found that British Columbia’s complex care incentive payments had no overall impact on the number of primary care contacts or continuity of care, nor did they reduce hospital admissions or total costs,” researchers wrote. “These findings contradict earlier claims of improved continuity and cost savings based on cross-sectional comparisons, but are generally consistent with previous research that has found limited impact of incentives within primary care.”

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The findings, however, do not necessarily translate to evidence of the incentive pay program’s failure, according to a commentary also published on the journal’s website. 

“Post-hoc evaluations of policy,” wrote Tara Kiran, MD, MSc, of the department of family and community Medicine, St Michael’s Hospital, University of Toronto, “are always tricky because the objectives of policy-makers are often unclear, the most relevant clinical data are usually unavailable, and it is impossible to cleanly disentangle the effect of the policy from other factors influencing outcomes.” 

The study leaves several important questions unanswered, she continued, including whether the incentive fee changed the management approach of primary care physicians, how physicians who received the fee implemented care plan recommendations, whether even the ideal implementation of care plans would reduce hospitalizations, and exactly what the government aimed to achieve through the program.

“Maybe they were trying to get physicians to accept more patients with complex illness, or address relative pay differences between family physicians and specialists,” Dr Kiran observed. “If the latter was the goal, then the policy was likely a success.”—Jolynn Tumolo

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