- A new study in JAMA Surgery found that providers with fee-for-service compensation performed more carotid stenosis interventions on symptomatic and asymptomatic patients compared to providers reimbursed by a salary.
Using data from the Military Health System’s TRICARE program between October 2006 to September 2010, researchers found that the odds ratio for carotid stenosis patients undergoing an intervention versus medical management was 1.629 for fee-for-service providers compared to salary-based providers.
“What is unique about the population in question is that, rather than demonstrating variation in health are by geography or over time, the current study demonstrates variation in healthcare use by clinician reimbursement type in a synchronous national cohort,” researchers wrote. “The finding that the odds of intervention are higher among patients in the PC [purchased care, fee-for-service] group compared with those in the DC [direct care, salary] group suggests that such variation may be associated with clinician compensation structure.”
Carotid stenosis is a narrowing of the blood vessels located in the neck that carry blood from the heart to the brain. The condition is preventable cause of ischemic stroke, a leading cause of death.
Patients with carotid stenosis generally have two options for treatment. Some providers treat carotid stenosis and lower patient risk of stroke through medical management, such as antiplatelet therapy, cholesterol control drug use, and hypertension control.
Other patients may undergo carotid endarterectomy, a surgical intervention. However, some clinical guidelines suggest that only symptomatic patients with 50 percent to 99 percent stenosis or asymptomatic patients with 60 percent to 99 percent stenosis receive the intervention. Patients should also have a good risk profile and the surgery should be performed by an experienced provider.
As expected, symptomatic carotid stenosis patients were significantly more likely to receive a carotid endarterectomy over medical management regardless of provider compensation model with an odds ratio of 9.487.
Similarly, patients with higher Hierarchical Condition Categories (HCC) scores were significantly less likely to undergo a carotid stenosis intervention regardless of provider compensation model with an odds ratio of 0.815.
Although, more patients went through a carotid endarterectomy when treated by a provider compensated via fee-for-service. Asymptomatic patients were more likely to undergo the intervention under a fee-for-service provider with an odds ratio of 1.534. Symptomatic patients saw similar results with an odds ratio of 2.074.
The results were consistent with previous research from 2010 that found primary care physicians increased encounter and procedure volumes after transitioning from a salary compensation model to a fee-for-service arrangement.
However, the JAMA Surgery study uncovered that more symptomatic carotid stenosis patients who fit the clinical guideline profile for appropriate intervention use received the carotid endarterectomy when treated by a fee-for-service provider.
“[O]ne would expect a higher rate of appropriate intervention in symptomatic patients; in turn, the comparative rate of intervention for these patients would suggest that the system performed at what could be thought to be a more appropriate level of care,” researchers wrote.
In other words, symptomatic patients treated by salary-based providers were less likely to receive an intervention that may have benefited them.
Study results indicated that fee-for-service compensation models were not linked to healthcare overutilization as some stakeholders believe. Instead, the salary compensation model was linked to healthcare underutilization.
The study concluded that healthcare stakeholders should use study results to develop provider compensation models that better align the incentives of providers and patients.
Other researchers have also suggested that healthcare organizations switch to more performance-based provider compensation strategies to further the value-based care transition. An October 2016 study from Deloitte’s Center for Health Solutions showed that 86 percent of primary care providers and specialists are primarily paid under fee-for-service or salary structures.
Only 30 percent of surveyed providers received compensation via value-based payment models in 2016, up just 5 percentage points from 2014.
The Deloitte survey revealed that value-based provider compensation is well below the 20 percent threshold that some healthcare experts have agreed would effectively spur providers to align their behaviors with value-based care.
Both the JAMA Surgery and Deloitte reports indicate that salary compensation models may not work to motivate providers to change to value-based care delivery, such as appropriate resource use.