$110 million for doctors to promote cancer screening didn’t help: study

Ontario doctors are handed an annual bonus based on how many of their patients are screened for three cancers. But even with this financial incentive, cancer screening rates aren’t improving, a new study suggests.

Between 2006 and 2010, the Ontario government doled out $110 million in bonuses meant to encourage doctors to screen their patients for cervical, breast and colorectal cancer. A St. Michael’s Hospital study released Monday warns that the payout hardly changed screening rates, though.

“So if you’ve screened more of your patients, you get a bigger bonus and if you’ve screened less, you get a small bonus. And there’s a threshold you have to meet to qualify for any money at all,” Dr. Tara Kiran, lead researcher and family doctor, told Global News.

“There’s actually very little evidence that pay for performance for family doctors improves quality of care,” she said.

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Yet using bonuses to motivate doctors is a tactic governments around the world are using. In the U.K., for example, Kiran said the “biggest experiment” is taking place: 25 per cent of physicians’ income is linked to certain targets they have to reach.

As far as Kiran knows, Ontario is the only jurisdiction in Canada with these preventative care cash bonuses. It started about a decade ago as the provincial government ushered in a string of reforms to primary care.

Kiran’s study tracked screening rates for cervical, breast and colorectal cancer across the province between 2000 and 2010. If doctors tested 60 per cent of their patients eligible for cervical cancer screening, they received $220 a year. If they hit 80 per cent of patients, it rose to $2,200. About 22 per cent of doctors cashed out with an extra $8,400 in 2010 in screening bonuses.

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But the increase in screening rates was hardly significant: cervical cancer screening increased from 55 to 57 per cent over a decade. Breast cancer screening rates increased from 60 per cent to 63. And screening for colorectal cancer rose from 20 to 51 per cent.

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The spike in the colorectal cancer category was expected, though – even before the incentives were phased in, screening was increasing on its own by three per cent each year.

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So why didn’t the incentives work? For starters, the researchers guess that the bonuses were targeting the wrong doctors – most were already on top of screening patients.

“The theory behind pay for performance is more money is going to motivate doctors to do a better job. But all the doctors I know are motivated to provide excellent care to begin with,” Kiran said.

(In one case, Toronto doctor Dr. Alisa Naiman said the bonus had “no impact” on how she practices. “The problem that I have with pay for performance is that sometimes it’s really about the process of informing somebody to go for it,” she told Global News.)

Instead, it may have to do with lack of the right tools to do a better job. Only 70 per cent of Ontario doctors have electronic medical records, and sometimes they’re not as helpful in keeping tabs on patients.

Patients in the meantime could be declining screening tests because of myths and misconceptions floating around. Others might not want the screening test conducted by their doctor of the opposite sex.

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But some programs have helped – reminders that you’re due for a screening test is a good start.

So far, Kiran has shared her findings with the Ontario Medical Association and the province’s health ministry.

Her full study was published Monday afternoon in the Annals of Family Medicine.