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:
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