Effect of physician specialist alternative payment plans on administrative health data in Calgary: a validation study.
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ABSTRACT: Background
There are concerns that alternate payment plans for physicians may be associated with erosion of data quality, given that physicians are paid regardless of whether claims are submitted. Our objective was to determine the proportion of claims submitted by physician specialists using fee-for-service and alternative payment plans, and to identify and compare the validity of information coded in physician billing claims submitted by these specialists in Calgary.Methods
We conducted a survey of physician specialists to determine their plan status and obtained consent to use physicians' claims data from 4 acute care hospitals in Calgary. Inpatient and emergency department services were identified from the Discharge Abstract Database for Alberta (Canadian Institute for Health Information) and the Alberta Ambulatory Care Classification System database. We linked services to claims by Alberta physicians from 2002 to 2009 by using unique patient and physician identifiers. After identifying the proportion of claims submitted, we reviewed inpatient charts to determine the completeness of submissions as defined by positive predictive value.Results
Of 182 physicians who responded to the survey, 94 (51.6%) used fee-for-service plans exclusively and 51 (28.0%) used alternative payment plans exclusively. Overall completeness of physician submissions for claims was 91.8% for physicians using fee-for-service plans and 90.0% for physicians using alternative payment plans. Submission rate varied by medical specialty (surgery: 92.4% for fee for service v. 88.6% for alternative payment; internal medicine: 94.1% v. 91.3%; neurology: 95.1% v. 91.0%; and pediatrics: 95.1% v. 89.3%). Among claims submitted, the physician accuracies for billing of medical conditions were 87.8% for fee-for-service and 85.0% for alternative payment.Interpretation
Overall submission rates and accuracy in recording diagnoses by physicians who used both plans were high. These findings show that the implementation of alternative payment plan programs in Alberta may not have an impact on the quality of physician claims data.
SUBMITTER: Cunningham CT
PROVIDER: S-EPMC4816270 | biostudies-literature | 2015 Oct-Dec
REPOSITORIES: biostudies-literature
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Effect of physician specialist alternative payment plans on administrative health data in Calgary: a validation study.
Cunningham Ceara Tess CT Jetté Nathalie N Li Bing B Dhanoa Ravneet Robyn RR Hemmelgarn Brenda B Noseworthy Tom T Beck Cynthia A CA Dixon Elijah E Samuel Susan S Ghali William A WA DeCoster Carolyn C Quan Hude H
CMAJ open 20151002 4
<h4>Background</h4>There are concerns that alternate payment plans for physicians may be associated with erosion of data quality, given that physicians are paid regardless of whether claims are submitted. Our objective was to determine the proportion of claims submitted by physician specialists using fee-for-service and alternative payment plans, and to identify and compare the validity of information coded in physician billing claims submitted by these specialists in Calgary.<h4>Methods</h4>We ...[more]
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Project description:ImportanceTiered physician network (TPN) health plans sort physicians into tiers based on their cost and quality, and patients pay lower copays for visits with physicians in the lower-cost and better-quality tiers. When the plans are first introduced, they lead patients to seek care from higher-value physicians.ObjectivesTo examine whether TPNs are associated with patient choice of physician when the plans have been in place for 8 to 12 years and whether there are inequities in patient out-of-pocket costs associated with inequities in access to physicians in lower-copay tiers.Design, setting, and participantsThis cross-sectional study comprising 46 645 physicians and 585 399 patients in TPNs, including 54 683 patients who had a new patient visit with a physician in a TPN, used health insurance claims data from a large employer purchaser from July 1, 2014, to June 30, 2019. Statistical analysis was performed from November 2020 to August 2023.ExposureEvaluation and management visit with a physician in a TPN.Main outcomes and measuresMain outcomes were new patient market share per physician-carrier-zip code-year, distance from centroid of patient zip code to centroid of zip code of nearest low- or medium-copay physician, and mean TPN physician office visit copay per patient. A regression discontinuity design was used to estimate the association of a physician's tier ranking, and a difference-in-differences analysis was used to estimate the association of copayment differences across tiers with market share among new patients. Equity in access was measured by comparing travel distance to the nearest physician in a low-copay or medium-copay tier and mean copayments across patient incomes.ResultsThe main analysis sample included 46 645 physician-carrier-zip code-year observations, 9506 (20.4%) of which were in the low-copay tier, 31 798 (68.2%) in the medium-copay tier, and 5341 (11.5%) in the high-copay tier. The 54 683 new patients in the sample had a mean (SD) age of 46.4 (16.7) years and included 33 542 women (61.3%). There was no association of having a worse tier ranking (0.045 percentage points [95% CI, -0.058 to 0.148 percentage points]) or of copayment differences between tiers (0.001 percentage points [95% CI, -0.002 to 0.004 percentage points]) with physician market share among new patients. The patients with the lowest income paid slightly lower mean (SD) copayments for office visits to a TPN physician than the patients with high income ($48.08 [$16.42] vs $51.59 [$16.79], a 6.8% difference).Conclusions and relevanceIn this cross-sectional study of TPN health plans, there was no association between physician tier ranking and physician market share among any group of patients. These findings suggest there are limitations in TPNs' steering of patients toward high-value physicians. These plans were not associated with exacerbated health inequity in this setting.
| S-EPMC10636632 | biostudies-literature
Project description:ImportanceConsolidation among physician practices and between hospitals and physician practices has accelerated in the past decade, resulting in higher prices in commercial markets. The resulting integration of health care across clinicians and participation in alternative payment models (APMs), which aim to improve quality while constraining spending, are cited as reasons for consolidation, but little is known about the association between integration and APM participation.ObjectiveTo examine the association of organizational characteristics, ownership, and integration with intensity of participation in APMs among physician practices.Design, setting, and participantsA cross-sectional descriptive study, adjusted for sampling and nonresponse weights, was conducted in US physician practice respondents to the National Survey of Healthcare Organizations and Systems conducted between June 16, 2017, and August 17, 2018; of 2333 responses received (response rate, 46.9%) and after exclusion of ineligible and incomplete responses, the number of practices included in the analysis was 2061. Data analysis was performed from April 1, 2019, to August 31, 2019.ExposuresSelf-reported physician practice characteristics, including ownership, integration (clinical, cultural, financial, and functional), care delivery capabilities, activities, and environmental factors.Main outcomes and measuresParticipation in APMs: (1) bundled payments, (2) comprehensive primary care and medical home programs, (3) pay-for-performance programs, (4) capitated contracts with commercial health plans, and (5) accountable care organization contracts.ResultsA total of 49.2% of the 2061 practices included reported participating in 3 or more APMs; most participated in pay-for-performance and accountable care organization models. Covariate-adjusted analyses suggested that operating within a health care system (odds ratio [OR] for medical group: 2.35; 95% CI, 1.70-3.25; P < .001; simple health system: 1.46; 95% CI, 1.08-1.97; P = .02; and complex health system: 1.76; 95% CI, 1.25-2.47; P = .001 relative to independent practices), greater clinical (OR, 4.68; 95% CI, 2.28-9.59; P < .001) and functional (OR, 4.24; 95% CI, 2.00-8.97; P < .001) integration, and being located in the Northeast (OR for Midwest: 0.47; 95% CI, 0.34-0.65; P < .001; South: 0.47; 95% CI, 0.34-0.66; P < .001; and West: 0.64; 95% CI, 0.46-0.91; P = .01) were associated with greater APM participation.Conclusions and relevanceGreater APM participation appears to be supported by integration and system ownership.
| S-EPMC7118519 | biostudies-literature
Project description:ObjectiveTo assess whether connections between physicians based on shared patients in administrative data correspond with professional relationships between physicians.Data sources/study settingSurvey of physicians affiliated with a large academic and community physicians' organization and 2006 Medicare data from a 100 percent sample of patients in the Boston Hospital referral region.Study design/data collectionWe administered a web-based survey to 616 physicians (response rate: 63 percent) about referral and advice relationships with physician colleagues. Relationships measured by this questionnaire were compared with relationships assessed by patient sharing, measured using 2006 Medicare data. Each physician was presented with an individualized roster of physicians' names with whom they did and did not share patients based on the Medicare data.Principal findingsThe probability of two physicians having a recognized professional relationship increased with the number of Medicare patients shared, with up to 82 percent of relationships recognized with nine shared patients, overall representing a diagnostic test with an area under the receiver-operating characteristic curve of 0.73 (95 percent CI: 0.70-0.75). Primary care physicians were more likely to recognize relationships than medical or surgical specialists (p<.001).ConclusionsPatient sharing identified using administrative data is an informative "diagnostic test" for predicting the existence of relationships between physicians. This finding validates a method that can be used for future research to map networks of physicians.
| S-EPMC3207194 | biostudies-literature
Project description:Importance:Specialist physicians are key members of chronic care management teams; to date, however, little is known about the association between specialist payment models and outcomes for patients with chronic diseases. Objective:To examine the association of payment model with visit frequency, quality of care, and costs for patients with chronic diseases seen by specialists. Design, Setting, and Participants:A retrospective cohort study using propensity-score matching in patients seen by a specialist physician was conducted between April 1, 2011, and September 31, 2014. The study was completed on March 31, 2015, and data analysis was conducted from June 2017 to February 2018 and finalized in August 2019. In a population-based design, 109 839 adults with diabetes or chronic kidney disease newly referred to specialists were included. Because patients seen by independent salary-based and fee-for-service (FFS) specialists were significantly different in observed baseline characteristics, patients were matched 1:1 on demographic, illness, and physician characteristics. Exposures:Specialist physician payment model (salary-based or FFS). Main Outcomes and Measures:Follow-up outpatient visits, guideline-recommended care delivery, adverse events, and costs. Results:A total of 90 605 patients received care from FFS physicians and 19 234 received care from salary-based physicians. Before matching, the patients seen by salary-based physicians had more advanced chronic kidney disease (2630 of 14 414 [18.2%] vs 6627 of 54 489 [12.2%]), and a higher proportion had 5 or more comorbidities (5989 of 19 234 [31.3%] vs 23 326 of 90 605 [25.7%]). Propensity-score matching resulted in a cohort of 31 898 patients (15 949 FFS, 15 949 salary-based) seeing 489 specialists. In the matched cohort, patients were similar (mean [SD] age, 61.3 [18.2] years; 17 632 women [55.3%]; 29 251 residing in urban settings [91.7%]). Patients seen by salary-based specialists had a higher follow-up visit rate compared with those seen by FFS specialists (1.74 visits; 95% CI, 1.58-1.92 visits vs 1.54 visits; 95% CI, 1.41-1.68 visits), but the difference was not significant (rate ratio, 1.13; 95% CI, 0.99-1.28; P = .06). There was no statistical difference in guideline-recommended care delivery, hospital or emergency department visits for ambulatory care-sensitive conditions, or costs between patients seeing FFS and salary-based specialists. The median association of physician clustering with health care use and quality outcomes was consistently greater than the association with the physician payment, suggesting variation between physicians (eg, median rate ratio for follow-up outpatient visit rate was 1.74, which is greater than the rate ratio of 1.13). Conclusions and Relevance:Specialist physician payment does not appear to be associated with variation in visits, quality, and costs for outpatients with chronic diseases; however, there is variation in outcomes between physicians. This finding suggests the need to consider other strategies to reduce physician variation to improve the value of care and outcomes for people with chronic diseases.
| S-EPMC6902778 | biostudies-literature
Project description:ImportanceWhile a gender pay gap in medicine has been well documented, relatively little research has addressed mechanisms that mediate gender differences in referral income for specialists.ObjectiveTo examine gender-based disparities in medical and surgical specialist referrals in Ontario, Canada.Design, setting, and participantsThis cross-sectional study included referrals for specialist care ascertained from Ontario Health Insurance Plan physician billings for fiscal year 2018 to 2019. Participants were specialist physicians who received new patient consultations from April 1, 2018, to March 31, 2019, and the associated referring physicians. Data were analyzed from April 2018 to March 2020, including a 12-month follow-up period.ExposuresSpecialist and referring physician gender (female or male).Main outcomes and measuresRevenue per referral was defined based on an episode-of-care approach as total billings for a 12-month period from the initial consultation. Mean total billings for female and male specialists were compared and the differential divided into the portion owing to referral volume vs referral revenue. Difference-in-differences multivariable regression analysis was used to estimate gender-based differences in revenue per referral. For each referring physician, gender-based differences in referral patterns were examined using case-control analysis, in which specialists who received a referral were compared with matched control specialists who did not receive a referral. This analysis considered the gender of the specialist and concordance between the gender of the referring physician and specialist, among other characteristics.ResultsOf 7 621 365 new referrals, 32 824 referring physicians, of whom 13 512 (41.2%) were female (mean [SD] age, 46.3 [11.6] years) and 19 312 (58.8%) were male (mean [SD] age, 52.9 [13.5] years), made referrals to 13 582 specialists, of whom 4890 (36.0%) were female (mean [SD] age, 45.6 [11.0] years) and 8692 (64.0%) were male (mean [SD] age, 51.8 [13.0] years). Male specialists received more mean (SD) referrals than did female specialists (633 [666] vs 433 [515]), and the mean (SD) revenue per referral was higher for males ($350 [$474]) compared with females ($316 [$393]). Adjusted analysis demonstrated a -4.7% (95% CI, -4.9% to -4.5%) difference in the revenue per referral between male and female specialists. Multivariable regression analysis found that physicians referred more often to specialists of the same gender (odds ratio, 1.04; 95% CI, 1.03-1.04) but had higher odds of referring to male specialists (odds ratio, 1.10; 95% CI, 1.09-1.11).Conclusions and relevanceIn this cross-sectional study of the gender pay gap in specialist referral income, the number and revenue from referrals received differed by gender, as did the odds of receiving a referral from a physician of the same gender. Future research should examine the effectiveness of different policies to address this gap, such as a centralized, gender-blinded referral system.
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Project description:BackgroundSurgery is the primary treatment for colorectal cancer for both curative and palliative intent. Availability of high quality surgery data is essential for assessing many aspects of the quality of colorectal cancer care. The objective of this study was to determine the quality of different administrative data sources in identifying surgery for colorectal cancer with respect to completeness and accuracy.MethodsAll residents in Alberta, Canada who were diagnosed with invasive colorectal cancer in years 2000-2005 were identified from the Alberta Cancer Registry and included in the study. Surgery data for these patients were obtained from the Cancer Registry (which collects the date of surgery for which the primary tumor was removed) and compared to surgery data obtained from two different administrative data sources: Physician Billing and Hospital Inpatient data. Sensitivity, specificity, positive predictive value, negative predictive value and observed agreement were calculated compared to the Cancer Registry data.ResultsThe Physician Billing data alone or combined with Hospital Inpatient data demonstrated equally high sensitivity (97% for both) and observed agreement with the Cancer Registry data (93% for both) for identifying surgeries. The Hospital Inpatient data, however, had the highest specificity (80%). The positive predictive value varied by disease stage and across data sources for stage IV (99% for stages I-III and 83-89% for stage IV), the specificity is better for colon cancer surgeries (72-85%) than for rectal cancer surgeries (60-73%); validation measures did not vary over time.ConclusionPhysician Billing data identify the colorectal cancer surgery more completely than Hospital Inpatient data although both sources have a high level of completeness.
| S-EPMC3406984 | biostudies-literature
Project description:ImportanceInteroperable patient data exchange across hospitals remains an important policy goal for reducing costs and improving the quality of care. Congress designated 2018 as the goal for nationwide interoperability, and policy makers hoped that aligning financial incentives via alternative payment models (APMs) would help achieve that goal.ObjectiveTo measure interoperability progress since 2014, assess the association between alternative payment model participation and hospital engagement in interoperable data sharing from 2014 to 2018, and evaluate hospital-reported barriers to interoperability in 2018.Design setting and participantsThis cohort study included nonfederal acute care hospitals in the US from January 2014 to December 2018 that responded to the American Hospital Association Annual Survey. Data were analyzed from October 2019 through March 2021.ExposuresParticipation in an APM, including accountable care organizations, bundled payments, or patient-centered medical homes.Main outcomes and measuresHospital engagement in all 4 domains of interoperability: finding/querying for data, sending data electronically, receiving data electronically, and integrating electronic patient data from external care delivery organizations.ResultsThe sample included 3928 hospitals in the US from January 2014 to December 2018. Progress across interoperability domains was uneven, 2430 (88.3%) hospitals sending and 2115 (76.9%) receiving patient data electronically in 2018. However, only 1249 (45.4%) hospitals engaged in all 4 domains of interoperability in 2018, and growth between 2014 and 2018 was slow. There was no evidence that participation in APMs was associated with interoperability, with multivariate models suggesting that participation in an APM was associated with only a non-statistically significant 1-percentage point increase in interoperability engagement (β = 0.01; 95% CI, -0.01 to 0.03). The most commonly cited barrier to interoperability was challenges associated with sharing data across different electronic health record vendors.Conclusions and relevanceIn this cohort study of hospital interoperability, fewer than half of US hospitals were engaged in interoperable data exchange in 2018. There was no observable evidence that hospital APM participation was associated with interoperability engagement. Many hospitals report technical and governance challenges to data sharing that are unlikely to be addressed by the alignment of financial incentives alone.
| S-EPMC8903122 | biostudies-literature
Project description:Ontario has a single payer provincial health insurance program. Administrative data may provide a potentially robust source of information for post-marketing vaccine studies. Vaccine-specific immunization billing codes were introduced in 2011. Our objective was to validate Ontario's universal health care administrative datasets to assess infant immunization status. Electronic medical record data from the Electronic Medical Record Administrative data Linked Database (EMRALD) was used as the reference standard to calculate performance characteristics of the Ontario Health Insurance Plan (OHIP) database vaccine-specific and general immunization codes for 4 primary infant immunizations: diphtheria, tetanus, acellular pertussis, inactivated polio, Haemophilus influenzae type B (DTaP-IPV-Hib) combination vaccine, pneumococcal conjugate vaccine, measles, mumps, rubella (MMR) vaccine, and meningococcal conjugate serogroup C vaccine. OHIP billing claims had specificity ranging from 81% to 92%, sensitivity 70% to 83%, positive predictive value (PPV) 97% to 99%, and negative predictive value (NPV) 13% to 46% for identifying the various specific vaccines in administrative data. For cohorts vaccinated in the new code introduction phase, using both the vaccine-specific and general codes had higher sensitivity than the vaccine-specific codes alone. In conclusion, immunization billing claims from administrative data in Ontario had high specificity and PPV, moderate sensitivity, and low NPV. This study identifies some of the applications of utilizing administrative data for post-marketing vaccine studies. However, limitations of these data decrease their utility for measuring vaccine coverage and effectiveness. Therefore, the establishment of a comprehensive and linkable immunization registry should be a provincial priority.
| S-EPMC4514409 | biostudies-literature
Project description:BackgroundLittle is known about the physician workforce providing palliative care in Canada, and in Ontario specifically. We developed an algorithm to identify palliative care physicians using administrative claims data and validated it against a reference sample. We then applied the algorithm to all general practitioners/family physicians (GP/FPs) in the province of Ontario to describe and quantify those identified by the algorithm.MethodsW e reviewed Ontario Health Insurance Plan claims from Jan. 1, 2008, to Dec. 31, 2011, to determine each physician's proportion of claims that were for palliative care. We empirically selected a data-driven cut-off, whereby physicians whose proportion of palliative care claims was above the threshold were defined as palliative care physicians. We validated the cut-off against a reference sample of physicians who self-identified as providing mostly palliative care in a study-specific survey. We then applied this algorithm to all GP/FPs in the province.ResultsWe empirically selected 10% as the cut-off for the proportion of palliative care claims. This threshold had exceptional specificity and positive predictive value (97.8% and 90.5%, respectively) and adequate sensitivity (76.0%) when compared with the reference sample (n = 118). When applied to all GP/FPs in the province, the algorithm identified 276 practising mostly palliative care. Of these, 135 (48.9%) were women, 265 (96.0%) practised in urban locations, and 145 (52.5%) worked part time.InterpretationOur algorithm readily identified and quantified the workforce of palliative care physicians in Ontario. Such a tool has numerous applications for both health service planners and researchers.
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Project description:BackgroundMixed payment schemes have become one of the effective measures to balance medical costs and quality of medical services. However, altruism as an intrinsic motivation may influence the effect of switching from a pure payment system to mixed payment schemes. This study aimed to quantify physicians' altruism and analyze the effect of changes of payment system on physicians' altruism and thus proposed references for the reform of payment system.MethodsWe simulated an exogenous payment system in a controlled laboratory with five experimental groups and 150 medical student subjects. Physicians' altruism was measured by estimating altruistic parameter and marginal rate of substitution. The non-parametric test and the least square regression analysis were used to analyze the differences of altruistic parameters between pure payment systems and mixed payment schemes. Finally, we analyzed the effect of changes in payment system accompanied by changes in trade-off range on physicians' altruism.ResultsWe find that the mean value of individual altruistic parameter is 0.78 and the marginal rate of substitution is 1.078. Their estimates at the individual level were significantly positively correlated (Spearman's ρ = 0.715, p < 0.01). The shift from pure payment system to mixed payment scheme reduced the altruistic parameter. However, the altruistic parameter increased with the increase of the trade-off range. Physicians who were more altruistic generated higher patients' health benefit. For each unit increase in altruistic parameter, the increase in patients' health benefit was lower in mixed payment scheme than in the pure payment system.ConclusionThe estimates of altruistic parameters are reliable. Physicians attach a higher weight to patients' benefit than to their own profit. Mixed payment schemes improve physicians' behavior and relate to lower altruistic parameters; physicians only need to sacrifice less personal profits to generate the same or even higher altruistic parameter as under the pure payment system. The design of mixed payment schemes that make the interests of physicians and patients close to each other by reducing the trade-off range can provide implication for the reform of payment system in which the physicians' interest and the patients' benefit are consistent.
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