(102) Do Payment Modalities Incentivize Screening for Unhealthy Alcohol Use in Ambulatory Care?

Background & Introduction: Despite recommendations, screening for unhealthy alcohol use occurs infrequently in ambulatory care settings. One oft-cited barrier to screening is misalignment of incentives, but it remains unclear which financial arrangements common in practice contribute to this misalignment. We investigate whether various determinants of income, for both practices and individual physicians, encourage or discourage guideline-concordant alcohol screening in ambulatory care visits.

Methods: Visit-level cross-sectional analysis using the National Ambulatory Medical Care Survey, 2015-2019. The analysis is limited to patients who are new to the practice or who had zero visits within the last 12 months, in alignment with screening guidance (n=10,607). We use logistic regression to test associations between the occurrence of alcohol screening with tools such as AUDIT, MAST, CAGE, T-ACE, etc. during a visit and variables capturing practice and physician income determinants. Practice income determinants include receipt of considerable patient revenue (>25% of revenue) from capitation and from Medicaid. Physician income determinants include payment by share of practice billings (versus salary, hourly, etc.), the consideration of measures in productivity and measures of patient satisfaction in determining compensation, and practice ownership. Models also control for practice type (e.g. physician group, academic medical center), solo versus multi-physician practice, practice electronic capabilities, physician specialty, visit length, and patient sex, race and ethnicity, age, and number of chronic conditions. Models include year fixed effects and incorporate complex survey design.

Results: Only 142 of the 10,607 visits under study included alcohol screening (2.9% of weighted sample). In the covariate adjusted model, we find that the odds of screening occurring were higher in visits to physicians for whom a considerable amount of revenue came from capitation compared to the odds of screening occurring in visits to physicians for whom less than 25% of revenue came from capitation (adjusted odds ratio (aOR)=6.076; 95% confidence interval (CI)=2.412, 15.307). We also find odds of screening occurring in visits to physicians for whom patient satisfaction was used to determine compensation were higher than odds of screening occurring in visits to physicians for whom patient satisfaction was not considered in compensation (aOR=3.466, 95% CI=1.471, 8.163). We did not find evidence that any other determinants were associated with screening.

Conclusion & Discussion: We find that, in a national sample of ambulatory care visits, guideline concordant screening for unhealthy alcohol use is infrequent and that the provision of screening is associated with the receipt of revenue via capitation and with the consideration of patient satisfaction measures in compensation determination. These results suggest that practice and physician income determinants that reward value and patient-centered outcomes, rather than productivity, may help incentivize alcohol screening. However, the low rates of alcohol screening observed suggest that transitioning towards such payment models may be one tool to use in the effort to improve screening rates but will likely need to be accompanied by training and other resources to facilitate screening processes.

References: U.S. Preventive Services Task Force. (2018). Unhealthy Alcohol Use in Adolescents and Adults: Screening and Behavioral Counseling interventions. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/unhealthy-alcohol-use-in-adolescents-and-adults-screening-and-behavioral-counseling-interventions#tab
Reif, S., Brolin, M., Beyene, T. M., D’Agostino, N., Stewart, M. T., & Horgan, C. M. (2022). Payment and Financing for Substance Use Screening and Brief Intervention for Adolescents and Adults in Health, School, and Community Settings. Journal of Adolescent Health, 71(4), S73–S82. https://doi.org/10.1016/j.jadohealth.2022.04.012
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