• Catherine Kim, Edward F Tierney, William H Herman, Carol M Mangione, K M Venkat Narayan, Robert B Gerzoff, Dori Bilik, and Susan L Ettner.
• Department of Medicine, Division of General Internal Medicine, University of Michigan, Ann Arbor, MI 48109-0429, USA. cathkim@umich.edu
• Am J Manag Care. 2009 Jan 1;15(1):32-8.

ObjectiveTo examine the association between physicians' reimbursement perceptions and outpatient test performance among patients with diabetes mellitus.Study DesignCross-sectional analysis.MethodsParticipants were physicians (n = 766) and their managed care patients with diabetes mellitus (n = 2758) enrolled in 6 plans in 2003. Procedures measured included electrocardiography, radiography or x-ray films, urine microalbumin levels, glycosylated hemoglobin levels, and Pap smears for women. Hierarchical logistic regression models were adjusted for health plan and physician-level clustering and for physician and patient covariates. To minimize confounding by unmeasured health plan variables, we adjusted for health plan as a fixed effect. Therefore, we estimated variation between physicians using only the variance within health plans.ResultsPatients of physicians who reported reimbursement for electrocardiography were more likely to undergo electrocardiography than patients of physicians who did not perceive reimbursement (unadjusted mean difference, 4.9%; 95% confidence interval, 1.1%-8.9%; and adjusted mean difference, 3.9%; 95% confidence interval, 0.2%-7.8%). For the other tests examined, no significant differences in procedure performance were found between patients of physicians who perceived reimbursement and patients of physicians who did not perceive reimbursement.ConclusionsReimbursement perception was associated with electrocardiography but not with other commonly performed outpatient procedures. Future research should investigate how associations change with perceived amount of reimbursement and their interactions with other influences on test-ordering behavior such as perceived appropriateness.

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