Association Between Capitated Payments and Low-Value Imaging in Primary Care
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J Gen Intern Med DOI: 10.1007/s11606-020-06265-4 © Society of General Internal Medicine 2020
INTRODUCTION
Led by Medicare, there is growing momentum to reform primary care payment using capitation.1, 2 Via fixed, recurring per-patient payments, capitation seeks to incentivize primary care clinicians and practices to improve value in part by reducing services that cause harm or provide little to no benefit (i.e., are low-value). As one type of low-value care with the potential to cause patient harm and increase health care costs, advanced imaging has been targeted by Medicare appropriate use criteria policy and national campaigns.3, 4 However, despite the potential for capitation incentives to reduce low-value imaging, little is known about this relationship. Therefore, we used two common primary care scenarios—advanced imaging done in the context of uncomplicated, new-onset low back pain (LBP) and headache—to examine the association between capitation and low-value imaging.
METHODS
We created a sample of outpatient visits from January 1, 2006, to December 31, 2015, using nationally representative data from the National Ambulatory Medical Care Survey (NAMCS), a probability sample of US nonfederal office-based visits each year provided by the National Center for Health Statistics. NAMCS includes data on reasons for visit, symptoms, diagnoses, diagnostic tests ordered, and practice characteristics. We limited our sample to visits performed by primary care clinicians (internal medicine, general medicine, and family medicine) and excluded visits for patients presenting with chronic symptoms and patients with cancer diagnoses. We followed approaches used in prior work and used information about diagnoses and reasons for visits to create two samples: one for uncomplicated, new-onset LBP and one for uncomplicated headache.5, 6
Our exposure was the proportion of patient care revenue accounted for by capitation, assessed across quartiles. As an alternate specification, we dichotomized the exposure variable into low (0–25%) versus high (26–100%) capitation revenue. Our outcome was ordering of CT or MRI in the setting of visits for uncomplicated, new-onset LBP or headache (“lowvalue advanced imaging”). We performed multivariable logistic regression, adjusted for patient and practice characteristics, to assess the association between capitation and low-value advanced imaging. Separate models were used for LBP and headache. All estimates were weighted to account for the complex multistage sampling design of NAMCS. Statistical tests were two-tailed and considered significant at alpha = 0.05. Analyses were performed using SAS version 9.4 (SAS Institute, Cary, NC). The University of Washington Institutional Review Board exempted this study from review due to use of publicly available data.
RESULTS
Our samples consisted of 1945 LBP visits and 936 headache visits. Low-value CT or MRI was ordered in 7.4% of LBP visits and 14% of headache visits. In adjusted analysis of LBP visits (Table 1), ordering of advanced imaging was not
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