The Relationship Between Financial Incentives and Quality of Diabetes Care in Ontario, Canada

OBJECTIVE: We assessed the impact of a diabetes incentive code introduced for primary care physicians in Ontario, Canada, in 2002 on quality of diabetes care at the population and patient level. RESEARCH DESIGN AND METHODS: We analyzed administrative data for 757,928 Ontarians with diabetes to examine the use of the code and receipt of three evidence-based monitoring tests from 2006 to 2008. We assessed testing rates over time and before and after billing of the incentive code. RESULTS: One-quarter of Ontarians with diabetes had an incentive code billed by their physician. The proportion receiving the optimal number of all three monitoring tests (HbA(1c), cholesterol, and eye tests) rose gradually from 16% in 2000 to 27% in 2008. Individuals who were younger, lived in rural areas, were not enrolled in a primary care model, or had a mental illness were less likely to receive all three recommended tests. Patients with higher numbers of incentive code billings in 2006-2008 were more likely to receive recommended testing but also were more likely to have received the highest level of recommended testing prior to introduction of the incentive code. Following the same patients over time, improvement in recommended testing was no greater after billing of the first incentive code than before. CONCLUSIONS: The diabetes incentive code led to minimal improvement in quality of diabetes care at the population and patient level. Our findings suggest that physicians who provide the highest quality care prior to incentives may be those most likely to claim incentive payments.