title: Physician perception of reimbursement for outpatient procedures among managed care patients with diabetes mellitus.
abstract: OBJECTIVE
  To examine the association between physicians' reimbursement perceptions and outpatient test performance among patients with diabetes mellitus.
  
  
  METHODS
  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.
authors.affiliation: Department of Medicine, Division of General Internal Medicine, University of Michigan, Ann Arbor, MI 48109-0429, USA. cathkim@umich.edu
authors.forename: Catherine
authors.initials: C
authors.lastname: Kim
authors.forename: Edward F
authors.initials: EF
authors.lastname: Tierney
authors.forename: William H
authors.initials: WH
authors.lastname: Herman
authors.forename: Carol M
authors.initials: CM
authors.lastname: Mangione
authors.forename: K M Venkat
authors.initials: KM
authors.lastname: Narayan
authors.forename: Robert B
authors.initials: RB
authors.lastname: Gerzoff
authors.forename: Dori
authors.initials: D
authors.lastname: Bilik
authors.forename: Susan L
authors.initials: SL
authors.lastname: Ettner
mesh_terms: D000328:Adult; D000553:Ambulatory Care / Q000191:economics / Q000379:methods; D001291:Attitude of Health Personnel; D003430:Cross-Sectional Studies; D003920:Diabetes Mellitus / Q000503:physiopathology; D003955:Diagnostic Tests, Routine / Q000191:economics / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010820:Physicians / Q000523:psychology*; D010818:Practice Patterns, Physicians' / Q000191:economics*; D012052:Reimbursement, Incentive