Ontario spent nearly $110 million dollars between 2006 and 2010 on bonuses to motivate family doctors to screen more of their patients for cancer but these bonuses were associated with little or no improvement in actual cancer screening rates, according to researchers at St. Michael's Hospital and the Institute for Clinical Evaluative Sciences (ICES).
The study, published today in Annals of Family Medicine, tracked screening rates for cervical, breast and colorectal cancer in Ontario each year between 2000 and 2010. Researchers found no significant changes in breast and cervical cancer screening rates after bonuses were introduced for doctors in 2006. The screening rate for colorectal cancer increased by 4.7 per cent per year after bonuses were introduced but it was already on the rise -- colorectal cancer screening was increasing by 3 per cent a year before the bonuses came into effect.
"Governments around the world are experimenting with paying doctors extra to improve the quality of care but there's actually very little evidence that this strategy works," said lead author Dr. Tara Kiran, a family physician and an associate scientist in the Li Ka Shing Knowledge Institute of St. Michael's Hospital.
Screening can catch cancer early and save lives. Pap tests screen for cervical cancer and mammograms are used to detect breast cancer. Colorectal cancer can be picked up by either a fecal occult blood test or a colonoscopy.
The amount doctors were paid varied based on the percentage of their appropriate patients -- determined by age and medical history -- who received the screening test. Physicians who had 60 per cent of their eligible patients screened for cervical cancer received $220 a year; the payment rose to $2,200 if 80 per cent were screened. In 2010, 84 per cent of eligible family doctors received at least one bonus payment and 22 per cent received the maximum bonus payment of $8,400 a year.
During the study period:
- The screening rate for cervical cancer increased from 55 to 57 per cent
- The screening rate for breast cancer increased from 60 to 63 per cent
- The screening rate for colorectal cancer increased from 20 to 51 per cent
"Some alternatives to physician bonuses include targeted outreach by identifying under-screened populations and directly approaching patients," said Dr. Rick Glazier, a senior scientist at ICES and research director in the Department of Family and Community Medicine of St. Michael's Hospital. "Public advertising campaigns in Ontario have been associated with increased screening rates."
The researchers point to many reasons why breast and cervical cancer screening rates may not be improving. For example, many family doctors in Ontario may not have the tools they need to generate electronic reminders that can trigger screening. There also may be patients who decline screening due to misconceptions or because they don't have access to a female provider to perform their Pap test.
- T. Kiran, A. S. Wilton, R. Moineddin, L. Paszat, R. H. Glazier. Effect of Payment Incentives on Cancer Screening in Ontario Primary Care. The Annals of Family Medicine, 2014; 12 (4): 317 DOI: 10.1370/afm.1664
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