The effects of payment method on clinical decision-making: physician responses to clinical scenarios.
BACKGROUND
The influence of payment mechanisms on physician decisions is not well understood.


OBJECTIVE
The objective of this study was to test 2 null hypotheses: 1) physicians' clinical decisions would not be influenced by payment incentives; and 2) physicians would have equal concern about medical decisions made under capitation or fee-for-service (FFS) arrangements.


METHODS
We conducted a physician survey in which patient insurance status (capitated or FFS) was randomly incorporated into 4 clinical scenarios using a Latin square design.


METHODS
We used a nationally representative random sample of family physicians in direct patient care.


METHODS
We used treatment decisions and physician "bother" scores (a measure of discomfort about decisions) in response to the clinical scenarios and adjusted for physician gender, age, board certification, income, practice location, practice mix, practice setting, geographic region, local area managed care penetration, and capitation or risk pool contracts in practice.


RESULTS
Seventy-two percent of sampled physicians responded. Comparing decisions made under capitation to FFS, physicians were less likely to indicate they would perform discretionary care (relative risks [RR] range, .64-.82; P<0.001), but payment had no effect on selection of life-saving care (RR, 1.02, not significant). Physicians felt significantly more "bothered" when they made clinical decisions under capitated payment (P<0.001 in all scenarios), regardless of whether a treatment was discretionary or life-saving, and whether the decision was made for or against the treatment (P<0.001).


CONCLUSIONS
Payment mechanism has significant effects on clinical decision-making. Reduction of resources spent for discretionary care might be achieved under capitated arrangements; however, physicians respond with greater levels of discomfort under capitation than FFS.
Shen
Joannie
J
Laboratory of Clinical Studies, National Institute on Alcoholism and Alcohol Abuse, National Institutes of Health, Bethesda, MD 20814-1610, USA. jshen@nih.gov
Andersen
Ronald
R
Brook
Robert
R
Kominski
Gerald
G
Albert
Paul S
PS
Wenger
Neil
N
D001291:Attitude of Health Personnel; D002055:Burnout, Professional / Q000209:etiology / Q000523:psychology; D002204:Capitation Fee / Q000458:organization & administration*; D002983:Clinical Competence; D003657:Decision Making; D018588:Fee-for-Service Plans / Q000458:organization & administration*; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D016014:Linear Models; D016015:Logistic Models; D008297:Male; D008329:Managed Care Programs / Q000458:organization & administration; D008875:Middle Aged; D017063:Outcome Assessment, Health Care / Q000458:organization & administration; D018579:Patient Selection; D010816:Physician Incentive Plans / Q000458:organization & administration; D010821:Physicians, Family / Q000458:organization & administration / Q000523:psychology; D010818:Practice Patterns, Physicians' / Q000458:organization & administration*; D011365:Professional Practice Location / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires; D014481:United States