UC Berkeley

Abstract

A Case Study: The Influence of Incentives

on the Use of Clinical Information Technology in Physician Organizations

by

Thomas Ryan Williams

Doctor of Public Health

University of California, Berkeley

Professor James C. Robinson, Chair

Background: The Institute of Medicine has called for increased adoption of information technology in U.S. healthcare to improve its quality and efficiency. In response, U.S. public and private purchasers of healthcare have developed pay for performance and other incentive programs to encourage physicians and physician organizations to implement Clinical Information Technology (CIT). Most notable, the American Recovery and Reinstatement Act (ARRA) of 2009 created a landmark program of Medicare and Medicaid payment incentives to encourage implementation of CIT by physicians in the form of electronic medical records, yet research about the influence of incentives on CIT use by physicians and physician organizations is scant.

Objectives: This study examines the nation's largest private pay for performance program and the response of its participating physician organizations to incentives for CIT use. The objectives of the study include determining the characteristics of physician organizations associated with the use of CIT; their response to direct and indirect financial incentives for its use; and the perceptions attributed to different types of CIT and to financial incentives by the leadership of physician organizations.

Study Design, Setting and Participants: A mixed-methods, retrospective case study of a pay for performance program from 2003 to 2007 including 206 physician organizations (POs) (2007) with individual physician association (IPA), medical group and foundation organizational structures. Forty-six percent (2003) to sixty-four percent (2007) of POs responded to an annual survey reporting use of 11 CITs and EHR use. A multi-variant regression analysis tested PO characteristics associated with CIT and EHR use and PO response to both direct and indirect incentives. A structured survey of PO leadership using a purposive sample of 35 POs (17%) in 2007 tested the perceived attributes of PO leaders regarding different types of CIT and financial incentives.

Main Outcome Measures: The extent of CIT use by POs (e.g., e-prescribing) on the basis of summary indices including population management CIT (0-3), point of care CIT (0-8), all CIT (0-11), electronic health record (EHR) use and PO characteristics associated with CIT and EHR use. The response to direct and indirect financial incentives by POs for CIT use using IT survey response and self-reporting of clinical results. The perceptions of PO leaders attributed to direct and indirect financial incentives and the CIT innovations examined in the study.

Results: Multi-variant regression analysis indicates the early use of population management CIT by POs is associated with PO geography, relative advantage and size. Early use of point of care CIT and EHR by POs is associated with PO geography, relative advantage and more highly structured organizational type.

This analysis further indicates the early response by POs to direct financial incentives for CIT use is associated with PO size, relative advantage and social networking. The early response by POs to indirect financial incentives for CIT use is associated with PO size, relative advantage, more highly structured organizational type and lower Medicaid payer mix.

The qualitative analysis of data collected from the PO Leadership Survey indicates that for most POs direct financial incentives for CIT use were not an important stimulus for new investments in CIT; however, these incentives did influence the types of CIT implemented. Conversely, this analysis indicates indirect financial incentives did stimulate earlier use of CIT by POs.

The PO Leadership Survey also indicates that the perceived operational risk of CIT innovations had a negative correlation with CIT use, and point of care CIT is perceived as more operationally risky than population management CIT. Furthermore, the perceived attributes including relative clinical advantage, relative financial advantage and trialability had a strong positive correlation with population management CIT innovations.

These results suggest that financial incentives influence the sequence and pace of CIT adoption by physician organizations.