Economic Incentives and Physicians' Delivery of Preventive Care: A Systematic Review

Division of Health Services Research and Policy, School of Public Health, University of Minnesota, Minneapolis, MN 55455, USA.
American Journal of Preventive Medicine (Impact Factor: 4.53). 03/2005; 28(2):234-40. DOI: 10.1016/j.amepre.2004.10.013
Source: PubMed


A systematic review of the randomized trial literature examining the impact of financial incentives on provider preventive care delivery was conducted. English-language studies published between 1966 and 2002 that addressed primary or secondary preventive care or health promotion behaviors were included in the review. Six studies that met the inclusion criteria were identified, which generated eight different findings. The literature is sparse. Of the eight financial interventions reviewed, only one led to a significantly greater provision of preventive services. The lack of a significant relationship does not necessarily imply that financial incentives cannot motivate physicians to provide more preventive care. The rewards offered in these studies tend to be small. Therefore, the results suggest that small rewards will not motivate doctors to change their preventive care routines.

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    • "Differences among age groups attenuated for some conditions; no changes in sex-related inequalities; reduced differences between most/least deprived areas on national level but not necessarily on local levels; mixed findings for ethnicity with reductions for some measures after QOF. Town et al. (2005) [25] 1 of 8 outcomes showed a significant effect. 1 significant difference found for feedback + bonus compared to control group. 1 study: P4P resulted in improved documentation. 1 study: $3 per extra immunization, which was deemed cost-effective as flu vaccines have been shown to save $117 in direct medical expenses in elderly. 1 study: feedback alone group was not different from control group. No difference between feedback + bonus vs. feedback only Neither type of payment nor type of preventive service drives lack of effect. "
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    ABSTRACT: BACKGROUND: A vast amount of literature on effects of pay-for-performance (P4P) in health care has been published. However, the evidence has become fragmented and it has become challenging to grasp the information included in it. OBJECTIVES: To provide a comprehensive overview of effects of P4P in a broad sense by synthesizing findings from published systematic reviews. METHODS: Systematic literature search in five electronic databases for English, Spanish, and German language literature published between January 2000 and June 2011, supplemented by reference tracking and Internet searches. Two authors independently reviewed all titles, assessed articles' eligibility for inclusion, determined a methodological quality score for each included article, and extracted relevant data. RESULTS: Twenty-two reviews contain evidence on a wide variety of effects. Findings suggest that P4P can potentially be (cost-)effective, but the evidence is not convincing; many studies failed to find an effect and there are still few studies that convincingly disentangled the P4P effect from the effect of other improvement initiatives. Inequalities among socioeconomic groups have been attenuated, but other inequalities have largely persisted. There is some evidence of unintended consequences, including spillover effects on unincentivized care. Several design features appear important in reaching desired effects. CONCLUSION: Although data is available on a wide variety of effects, strong conclusions cannot be drawn due to a limited number of studies with strong designs. In addition, relevant evidence on particular effects may have been missed because no review has explicitly focused on these effects. More research is necessary on the relative merits of P4P and other types of incentives, as well as on the long-term impact on patient health and costs.
    Health Policy 02/2013; 110(2-3). DOI:10.1016/j.healthpol.2013.01.008 · 1.91 Impact Factor
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    • "We feel that this model represents a contribution to the principal-multiagent literature on ex ante moral hazard which has not been yet explored. While most preventive efforts are ultimately in the hands of consumers, many consumers look to providers for guidance and direction in prevention (Town et al., 2005), and thus the provider's incentives need to be considered. "
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    ABSTRACT: A major factor in the cost of the U.S. healthcare system is related to the strategic behavior of system participants based on their incentives. Contracts may be used to align incentives in such distributed systems. We consider an insurer contracting with two agents, a consumer and a provider. We focus on the trade off between ex ante moral hazard and insurance, and consider both consumer and provider incentives to solve the problem of optimal contracting in the presence of unobservable preventive efforts. We consider two classes of efforts on behalf of the provider: those which would complement consumer efforts, and those which substitute with consumer efforts. Our results show that the provider must be given incentives when the consumer is healthy to induce effort, and that inducing provider effort allows an insurer to save on incentives given to the consumer. The insurer can save informational costs by using a multilateral contract compared to the bilateral benchmark. We provide an illustrative example showing which model features affect the overall savings that the multilateral contract achieves.
    Health Economics 04/2011; DOI:10.2139/ssrn.1814105 · 2.23 Impact Factor
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    • "One factor which likely contributed to the difference in study retrieval is the focus of some reviews on only one subset of medical conditions (e.g. prevention) [16,18,20], on one setting [13] or one study design [10]. Our review purposely focused on both primary care and hospital care without a restriction on medical condition. "
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    ABSTRACT: Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness. The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers. One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level. P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.
    BMC Health Services Research 08/2010; 10(1):247. DOI:10.1186/1472-6963-10-247 · 1.71 Impact Factor
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