The Impact of Physician Bonuses, Enhanced Fees, and Feedback on Childhood Immunization Coverage Rates

Montefiore Medical Center, New York, New York, United States
American Journal of Public Health (Impact Factor: 4.55). 02/1999; 89(2):171-5. DOI: 10.2105/AJPH.89.2.171
Source: PubMed


The purpose of this study was to examine the effects on immunization coverage of 3 incentives for physicians--a cash bonus for practice--wide increases, enhanced fee for service, and feedback.
Incentives were applied at 4-month intervals over 1 year among 60 inner-city office-based pediatricians. At each interval, charts of 50 randomly selected children between 3 and 35 months of age were reviewed per physician.
The percentage of children who were up to date for diphtheria, tetanus, and pertussis and Haemophilus influenzae type b; polio; and measles-mumps-rubella immunization in the study's bonus group improved by 25.3 percentage points (P < .01). No significant changes occurred in the other groups. However, percentage of immunizations received outside the participating practice also increased significantly in the bonus group (P < .01). Levels of missed opportunities to immunize were high in all groups and did not change over time. Physicians' knowledge of contraindications was low.
Bonuses sharply and rapidly increased immunization cover-age in medical records. However, much of the increase was the result of better documentation. A bonus is a powerful incentive, but more structure or education may be necessary to achieve the desired results.

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    • "Another disadvantage of practitioner-based incentive programs is that the incentives may reinforce reporting of health care improvements, even in the absence of any change in care. Such “improvements” may result from more accurate record keeping,4,82 or they may result from practitioners’ attempts to game the incentive-based intervention.83 For better or worse, whichever behavior is reinforced is the only one that is guaranteed to increase. "
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    • "We were not able to measure, however, a preintervention trend and look for a deviation from prior trends. Lastly, the data used for this study were not amenable to differentiating between better documentation and more complete immunization of the target population as has been noted in previous studies (Fairbrother et al. 1999, 2001). Differentiating between quality documentation and quality of care is an important distinction, but we have reason to believe that the overall quality of immunization documentation is more accurate and reliable than 15 years ago when previous studies noted that documentation and underlying care were dissociated. "
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