Abstract
OBJECTIVES: Provider organizations are increasingly entering risk-based payment contracts with incentives to minimize medical expenditures. Little is known about physicians' role in controlling costs. This systematic review aims to identify and characterize physician-mediated cost-management interventions in risk-bearing organizations, assess their effectiveness, and evaluate the quality of the literature.
STUDY DESIGN: Systematic literature review.
METHODS: We searched PubMed and EconLit for studies published between 2000 and 2021 reporting physician-mediated interventions intended to reduce medical expenditures in risk-bearing provider organizations. We included quantitative studies evaluating single interventions, quantitative survey-based studies, and qualitative case studies. The quality of the quantitative studies was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework.
RESULTS: Twenty-seven studies were identified, including 12 quantitative evaluations, across diverse provider settings and payment models. We found 5 types of interventions: decision support and performance review, individual financial incentives, physician-led care management, expanded access, and provider-facing price transparency. All but 1 evaluation study found a statistically significant reduction in spending or utilization, but no intervention achieved substantial savings relative to total medical expenditures. The quality of this literature is low, with only 3 studies using a randomized controlled design. Generalizability of results to different provider contexts and payment models remains unclear.
CONCLUSIONS: There is a striking scarcity of high-quality studies on physician-mediated interventions to manage total medical expenditures. The limited evidence to date suggests that no single intervention has a substantial impact on total medical expenditures. Risk-bearing providers have limited guidance in the literature on the most effective practices clinicians can adopt to improve cost-related performance in risk-based contracts.