title: Doing More for More: Unintended Consequences of Financial Incentives for Oncology Specialty Care.
abstract: BACKGROUND
  Specialty care remains a significant contributor to health care spending but largely unaddressed in novel payment models aimed at promoting value-based delivery. Bladder cancer, chiefly managed by subspecialists, is among the most costly. In 2005, Centers for Medicare and Medicaid Services (CMS) dramatically increased physician payment for office-based interventions for bladder cancer to shift care from higher cost facilities, but the impact is unknown. This study evaluated the effect of financial incentives on patterns of fee-for-service (FFS) bladder cancer care.
  
  
  METHODS
  Data from a 5% sample of Medicare beneficiaries from 2001-2013 were evaluated using interrupted time-series analysis with segmented regression. Primary outcomes were the effects of CMS fee modifications on utilization and site of service for procedures associated with the diagnosis and treatment of bladder cancer. Rates of related bladder cancer procedures that were not affected by the fee change were concurrent controls. Finally, the effect of payment changes on both diagnostic yield and need for redundant procedures were studied. All statistical tests were two-sided.
  
  
  RESULTS
  Utilization of clinic-based procedures increased by 644% (95% confidence interval [CI] = 584% to 704%) after the fee change, but without reciprocal decline in facility-based procedures. Procedures unaffected by the fee incentive remained unchanged throughout the study period. Diagnostic yield decreased by 17.0% (95% CI = 12.7% to 21.3%), and use of redundant office-based procedures increased by 76.0% (95% CI = 59% to 93%).
  
  
  CONCLUSIONS
  Financial incentives in bladder cancer care have unintended and costly consequences in the current FFS environment. The observed price sensitivity is likely to remain a major issue in novel payment models failing to incorporate procedure-based specialty physicians.
authors.affiliation: Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR). brock.oneil@vanderbilt.edu.
authors.forename: Brock
authors.initials: B
authors.lastname: O'Neil
authors.affiliation: Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR).
authors.forename: Amy J
authors.initials: AJ
authors.lastname: Graves
authors.affiliation: Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR).
authors.forename: Daniel A
authors.initials: DA
authors.lastname: Barocas
authors.affiliation: Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR).
authors.forename: Sam S
authors.initials: SS
authors.lastname: Chang
authors.affiliation: Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR).
authors.forename: David F
authors.initials: DF
authors.lastname: Penson
authors.affiliation: Department of Urologic Surgery, Vanderbilt University, Nashville, TN (BO, AJG, DAB, SSC, DFP, MJR); Geriatric Research Education and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, TN (DFP, MJR).
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Resnick
mesh_terms: D000556:Ambulatory Surgical Procedures / Q000191:economics*; D018588:Fee-for-Service Plans / Q000191:economics* / Q000639:trends; D005260:Female; D006801:Humans; D008297:Male; D008484:Medicaid; D008495:Medical Oncology / Q000191:economics*; D006278:Medicare; D009042:Motivation; D010342:Patient Acceptance of Health Care / Q000706:statistics & numerical data*; D010820:Physicians / Q000191:economics*; D014481:United States; D001749:Urinary Bladder Neoplasms / Q000191:economics* / Q000601:surgery*