Physician Perception of Reimbursement for Outpatient Procedures Among Managed Care Patients With Diabetes Mellitus

Perception of reimbursement was associated with electrocardiography but not with other common outpatient procedures. Future research should investigate how associations change with perceived reimbursement amount.
Published Online: January 01, 2009
Catherine Kim, MD, MPH; Edward F. Tierney, MPH; William H. Herman, MD, MPH;
Objective: To examine the association between physicians’ reimbursement perceptions and outpatient test performance among patients with diabetes mellitus.

Study Design: Cross-sectional analysis.

Methods: Participants were physicians (n = 766) and their managed care patients with diabetes mellitus (n = 2758) enrolled in 6 plans in 2003. Procedures measured included electrocardiography, radiography or x-ray films, urine microalbumin levels, glycosylated hemoglobin levels, and Pap smears for women. Hierarchical logistic regression models were adjusted for health plan and physician-level clustering and for physician and patient covariates. To minimize confounding by unmeasured health plan variables, we adjusted for health plan as a fixed effect. Therefore, we estimated variation between physicians using only the variance within health plans.

Results: Patients of physicians who reported reimbursement for  electrocardiography were more likely to undergo electrocardiography than patients of physicians who did not perceive reimbursement (unadjusted mean difference, 4.9%; 95% confidence interval, 1.1%-8.9%; and adjusted mean difference, 3.9%; 95% confidence interval, 0.2%-7.8%). For the other tests examined, no significant differences in procedure performance were found between patients of physicians who perceived reimbursement and patients of physicians who did not perceive reimbursement.

Conclusions: Reimbursement perception was associated with electrocardiography but not with other commonly performed outpatient procedures. Future research should investigate how associations change with perceived amount of reimbursement and their interactions with other influences on test-ordering behavior such as perceived appropriateness.
(Am J Manag Care. 2009;15(1):32-38)
In managed care, perceptions of reimbursement for particular outpatient procedures have inconsistent associations with test ordering among primary care physicians who care for patients with diabetes mellitus. Previous studies have documented an association between reimbursement perceptions and performance of electrocardiography but not for other common outpatient procedures.
  • Associations may exist for electrocardiography but not for recommended diabetes care measures such as urine microalbumin or glycosylated hemoglobin monitoring, screening measures such as Pap smears, or other diagnostic tests such as radiography.
  • To improve performance of certain measures, additional interventions may be necessary, including greater physician detailing, levels of reimbursement, and discussion of appropriateness.

Author Affiliations: From the Department of Medicine (CK, WHH, DB), the Department of Obstetrics & Gynecology (CK), and the Department of Epidemiology (WHH), University of Michigan, Ann Arbor; the Division of Diabetes Translation (EFT, RBG), Centers for Disease Control and Prevention, Atlanta, GA; the Department of Medicine (CMM, SLE), University of California, Los Angeles; and the Rollins School of Public Health (KMVN), Emory University, Atlanta, GA.

Author Disclosure: The authors report no relationship or financial interest with any entity that would pose a conflict of interest with the subject matter of this article.

Funding Source: TRIAD was supported by grant U58/CCU523525-03 from the Centers for Disease Control and Prevention (CDC). This study was jointly funded by Program Announcement 04005 from the CDC (Division of Diabetes Translation) and the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK). Dr Kim was supported by grant K23DK071552 from the NIDDK. This research utilized the Biostatistics and Measurement Cores of the Michigan Diabetes Research and Training Program funded by grant NIH 5P60 DK20572 from the NIDDK. Dr Mangione was partially supported by grant AG-02-004 from the University of California at Los Angeles Center for Health Improvement in Minority Elders/Resource Centers for Minority Aging Research, National Institutes of Health/National Institute on Aging.

Authorship Information: Concept and design (CK, WHH, CMM, KMVN, SLE); acquisition of data (CK, EFT, WHH, CMM, RBG, SLE); analysis and interpretation of data (CK, EFT, CMM, KMVN, RBG, SLE); drafting of the manuscript (CK, CMM, KMVN, DB, SLE); critical revision of the manuscript for important intellectual content (CK, EFT, WHH, CMM, KMVN, RBG, DB, SLE); statistical analysis (CK, EFT, RBG, DB, SLE); obtaining funding (WHH, CMM); and administrative, technical, or logistic support (WHH, DB).

Address correspondence to: Catherine Kim, MD, MPH, Division of General Internal Medicine, University of Michigan, 300 N Ingalls Bldg, Rm 7C13, Ann Arbor, MI 48109-0429. E-mail:
1. Ettner SL, Thompson TJ, Stevens MR, et al; the TRIAD Study Group. Are physician reimbursement strategies associated with processes of care and patient satisfaction for patients with diabetes in managed care? Health Serv Res. 2006;41(4, pt 1):1221-1241.
2. Shortell SM, Schmittdiel J, Wang MC, et al. An empirical assessment of high-performing medical groups: results from a national study. Med Care Res Rev. 2005;62(4):407-434.
3. Casalino L, Gilies RR, Shortell SM, et al. External incentives, informational technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA. 2003;289(4):434-441.
4. van der Weijden T, van Velsen M, Dinant GJ, van Hasselt CM, Grol R. Unexplained complaints in general practice: prevalence, patients’ expectations, and professionals’ test-ordering behavior. Med Decis Making. 2003;23(3):226-231.
5. Robinson JC. Theory and practice in the design of physician payment incentives. Milbank Q. 2001;79(2):149-177.
6. Epstein AM, Begg CB, McNeil BJ. The use of ambulatory testing in prepaid and fee-for-service group practices: relation to perceived profitability. N Engl J Med. 1986;314(17):1089-1094.
7. Epstein AM, Krock SJ, McNeil BJ. Office laboratory tests: perceptions of profitability. Med Care. 1984;22(2):160-166.
8. Greenfield S, Rogers W, Mangotich M, Carney MF, Tarlov AR. Outcomes of patients with hypertension and non–insulin dependent diabetes mellitus treated by different systems and specialties: results from the Medical Outcomes Study. JAMA. 1995;274(18):1436-1444.
9. Rosenthal MB, Landon BE, Normand SL, Frank RG, Epstein AM. Pay for performance in commercial HMOs. N Engl J Med. 2006;355(18):1895-1902.
10. Ware J Jr, Kosinski M, Keller SD. A 12-item short-form health survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34(3):220-233.
11. Hillman AL, Ripley K, Goldfarb N, Nuamah I, Weiner J, Lusk E. Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care. Am J Public Health. 1998;88(11):1699-1701.
12. Hillman AL, Ripley K, Goldfarb N, Weiner J, Nuamah I, Lusk E. The use of physician financial incentives and feedback to improve pediatric preventive care in Medicaid managed care. Pediatrics. 1999;104(4, pt 1):931-935.
13. Exhibit 2.3: Health Plan Enrollment for Covered Workers, by Plan Type, 1988-2005, Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2005. Accessed December 24, 2008.
14. TRIAD Study Group. The Translating Research Into Action for Diabetes (TRIAD) study: a multicenter study of diabetes in managed care. Diabetes Care. 2002;25(2):386-389.
15. Brown AE, Gregg EW, Stevens MR, et al. Race, ethnicity, socioeconomic position, and quality of care for adults with diabetes enrolled in managed care: the Translating Research Into Action for Diabetes (TRIAD) study. Diabetes Care. 2005;28(12):2864-2870.
16. Raghunathan TE, Solenberger P, Van Hoewyk J. IVEware: Imputation and Variance Estimation Software User Guide. Ann Arbor: Survey Methodology Program, Survey Research Center, Institute for Social Research, University of Michigan, 2007.
17. Keating NL, Landrum MB, Landon BE, et al. The influence of physicians’ practice management strategies and financial arrangements on quality of care among patients with diabetes. Med Care. 2004;42(9):829-839.
18. Kim C, Steers WN, Herman WH, Mangione CM, Narayan KM, Ettner SL. Physician compensation from salary and quality of diabetes care. J Gen Intern Med. 2007;22(4):448-452.
19. Mehrotra A, Pearson SD, Coltin KL, et al. The response of physician groups to P4P incentives. Am J Manag Care. 2007;13(5):249-255.
20. Young GJ, Meterko M, Beckman H, et al. Effects of paying physicians based on their relative performance for quality. J Gen Intern Med. 2007;22(6):872-876.
21. Levin-Scherz J, DeVita N, Timbie J. Impact of pay-for-performance contracts and network registry on diabetes and asthma HEDIS measures in an integrated delivery network. Med Care Res Rev. 2006;63 (1 suppl):14S-28S.


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