In the Journals

Incentives to psychiatrists do not increase access to follow-up care

David Rudoler

Payment incentives used to encourage psychiatrists to see new patients after discharge from a psychiatric hospital or a suicide attempt did not increase access to follow-up care and had no effect on supply of psychiatric services, according to data published in Canadian Medical Association Journal.

“In September 2011, the government of Ontario introduced bonus payments to encourage psychiatrists to provide rapid access to patients within 30 days of discharge after a psychiatric hospital admission and for 6 months after a suicide attempt,” David Rudoler, PhD, from the Centre for Addiction and Mental Health at the University of Toronto, and colleagues wrote. “By encouraging the delivery of follow-up care, the objective of these incentives was to help reduce the risk of deterioration, early readmission to hospital and possibly further suicide attempts.”

Researchers evaluated whether psychiatrists changed their practice patterns and whether high-risk patients had better access to psychiatrists after the introduction of these incentives in 2011. Specifically, they examined whether the incentives affected the quantity of eligible outpatient services delivered and the probability of receiving follow-up care using interrupted time-series analyses of psychiatrist-level and patient-level data in Ontario between September 2009 and August 2014.

"We found that pay-for-performance incentives for psychiatrists did not improve access to psychiatric care for persons with severe mental illness, including those with a recent suicide attempt,” Rudoler told Healio Psychiatry.

Of 1,921 psychiatrists included in this study, implementation of the incentive payments was not connected to increased delivery of follow-up visits after discharge from a psychiatric hospital (mean change in visits per month per psychiatrist: 0.0099 [95% CI, –0.0989 to 0.1206]; change in trend: 0.0032 [95% CI, –0.0035 to 0.0095]) or after a suicide attempt (mean change: –0.091 [95% CI, –0.1885 to 0.0026]; change in trend: 0.0102 [95% CI, 0.0045-0.0159]).

“While the financial incentives were well-intentioned, access to timely mental health care is a complex problem,” Rudoler said. “We should not expect complex problems to be solved with simple solutions."

Furthermore, there was also no change in the likelihood that patients received follow-up care postdischarge (change in level: –0.0079 [95% CI, –0.0223 to 0.0061]; change in trend: 0.0007 [95% CI, –0.0003 to 0.0016]) or after a suicide attempt (change in level: 0.0074 [95% CI –0.0094 to 0.0366]; change in trend: 0.0006 [95% CI –0.0007 to 0.0022]).

“Although we focused on the situation in Ontario, our findings will be important for policy-makers in all high-income countries where the use of payment incentives to improve health care delivery is an important concern,” Rudoler and colleagues wrote. “Our results ... indicate that careful thought should be given to the design of such incentives and the context in which they are implemented. As it stands, the provincial investment in these incentive payments has not produced any discernible value, and psychiatrists are not responding.” – by Savannah Demko

Disclosures: The authors report no relevant financial disclosures.

David Rudoler

Payment incentives used to encourage psychiatrists to see new patients after discharge from a psychiatric hospital or a suicide attempt did not increase access to follow-up care and had no effect on supply of psychiatric services, according to data published in Canadian Medical Association Journal.

“In September 2011, the government of Ontario introduced bonus payments to encourage psychiatrists to provide rapid access to patients within 30 days of discharge after a psychiatric hospital admission and for 6 months after a suicide attempt,” David Rudoler, PhD, from the Centre for Addiction and Mental Health at the University of Toronto, and colleagues wrote. “By encouraging the delivery of follow-up care, the objective of these incentives was to help reduce the risk of deterioration, early readmission to hospital and possibly further suicide attempts.”

Researchers evaluated whether psychiatrists changed their practice patterns and whether high-risk patients had better access to psychiatrists after the introduction of these incentives in 2011. Specifically, they examined whether the incentives affected the quantity of eligible outpatient services delivered and the probability of receiving follow-up care using interrupted time-series analyses of psychiatrist-level and patient-level data in Ontario between September 2009 and August 2014.

"We found that pay-for-performance incentives for psychiatrists did not improve access to psychiatric care for persons with severe mental illness, including those with a recent suicide attempt,” Rudoler told Healio Psychiatry.

Of 1,921 psychiatrists included in this study, implementation of the incentive payments was not connected to increased delivery of follow-up visits after discharge from a psychiatric hospital (mean change in visits per month per psychiatrist: 0.0099 [95% CI, –0.0989 to 0.1206]; change in trend: 0.0032 [95% CI, –0.0035 to 0.0095]) or after a suicide attempt (mean change: –0.091 [95% CI, –0.1885 to 0.0026]; change in trend: 0.0102 [95% CI, 0.0045-0.0159]).

“While the financial incentives were well-intentioned, access to timely mental health care is a complex problem,” Rudoler said. “We should not expect complex problems to be solved with simple solutions."

Furthermore, there was also no change in the likelihood that patients received follow-up care postdischarge (change in level: –0.0079 [95% CI, –0.0223 to 0.0061]; change in trend: 0.0007 [95% CI, –0.0003 to 0.0016]) or after a suicide attempt (change in level: 0.0074 [95% CI –0.0094 to 0.0366]; change in trend: 0.0006 [95% CI –0.0007 to 0.0022]).

“Although we focused on the situation in Ontario, our findings will be important for policy-makers in all high-income countries where the use of payment incentives to improve health care delivery is an important concern,” Rudoler and colleagues wrote. “Our results ... indicate that careful thought should be given to the design of such incentives and the context in which they are implemented. As it stands, the provincial investment in these incentive payments has not produced any discernible value, and psychiatrists are not responding.” – by Savannah Demko

Disclosures: The authors report no relevant financial disclosures.