A Payment Incentive to Improve Confirmatory Testing in Men With Prostate Cancer.

Importance: Among men with favorable-risk (ie, low-risk or favorable intermediate-risk) prostate cancer, confirmatory testing substantially improves the detection of aggressive cancers that may merit treatment instead of conservative management. Despite guideline recommendations, confirmatory testing is inconsistently used, and more than half of men do not receive it. Value-based interventions and payment incentives may improve care quality by motivating adherence to guideline-concordant care. Objective: To examine the use of confirmatory testing among men with low-risk prostate cancer, after the application of a multifaceted intervention, which included physician education and a payment incentive, sponsored by a commercial payer to support its use. Design, Setting, and Participants: This cohort study used data from the Michigan Urological Surgery Improvement Collaborative on men who received a diagnosis of low-risk prostate cancer between January 1, 2017, and July 1, 2022, with a minimum 6 months of follow-up. Statistical analysis was performed from October 2024 to June 2025. Exposure: Multifaceted intervention with a payment incentive, applied specifically to men who received a diagnosis of low-risk prostate cancer between April 1, 2018, and May 30, 2019. On meeting the payment incentive's benchmark (ie, ≥45% of men with low-risk prostate cancer complete confirmatory testing within 6 months of diagnosis), the insurer would distribute enhanced reimbursement on claims covered by commercial preferred provider organization plans. Main Outcomes and Measures: Confirmatory testing completion (ie, magnetic resonance imaging before or after diagnostic biopsy, repeat prostate biopsy, or genomics test) relative to the preincentive period among men with low-risk prostate cancer. Secondary analyses examined practices by baseline confirmatory testing completion and proportion of patients with insurance plans covered by the insurer sponsoring the payment incentive. Results: The study included 6609 patients (median age, 65 years [IQR, 60-70 years]), of whom 72.9% (n = 4818) elected for active surveillance. Confirmatory testing increased between 2017 (44.6% [725 of 1625]) and 2022 (64.3% [774 of 1203]) (P < .001). During the payment incentive period, patients had a 7.5% (95% CI, 0.0%-15.4%; P = .06) increase in the predicted probability of confirmatory testing completion relative to the preincentive period, although this change was not statistically significant (odds ratio, 1.43 [95% CI, 0.99-2.09]; P = .06). Conclusions and Relevance: In this cohort study of men with prostate cancer, confirmatory testing completion improved over the study period. However, the payment incentive was not associated with a robust increase in its use. The results suggest collaboration between payers and physicians has the potential to improve measures of prostate cancer care quality, but also highlight the challenges associated with payment incentives and alternative payment model implementation.