Do Payment Methods Incentivize Screening for Unhealthy Alcohol Use in Ambulatory Care Settings? Evidence from the US National Ambulatory Medical Care Survey

Despite recommendations, screening for unhealthy alcohol use occurs infrequently in US ambulatory care. One barrier to screening often cited by physicians is misalignment of incentives, but it is unclear which financial arrangements contribute to or alleviate this misalignment. This analysis investigates how determinants of income-both patient care revenue and physician remuneration-encourage or discourage guideline-concordant alcohol screening. Cross-sectional data from the US National Ambulatory Medical Care Survey 2015, 2016, 2018, and 2019 are pooled. Covariate-adjusted logistic regression is used to estimate associations between alcohol screening during visits and variables capturing methods of patient care revenue generation and of physician remuneration. Methods of revenue generation include receipt of revenue from capitation and Medicaid. Methods of physician remuneration include payment by share of practice billings, consideration of productivity and patient satisfaction in determining compensation, and practice ownership. Of 10,607 visits under study, fewer than 3% included screening. In the adjusted model, visits to physicians who received > 25% of patient revenue from capitated payments had higher odds of including screening (adjusted odds ratio (aOR) = 5.94; 95% confidence interval (CI) = 2.33, 15.13) compared with visits to physicians who received less from capitation, as did visits to physicians for whom patient satisfaction surveys impacted compensation (aOR = 3.56; 95% CI = 1.51, 8.37). Payment methods that reward value (e.g., capitation) and patient-centered outcomes (e.g., patient satisfaction), rather than productivity, may promote alcohol screening in US ambulatory care. However, the low rates of screening observed suggest transitioning towards such methods will not be sufficient to achieve optimal screening rates.