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PubMed1986

Improvement in coverage of primary health care in a developing country through use of food incentives.

To improve attendance at mobile clinics for children food incentives were offered to attenders in a rural municipality in northern Nicaragua. Clinic attendance in villages where food incentives were offered was higher than that in control villages (96.5% vs 63.3% of child population, p less than 0.005). When food was later offered in control villages, attendance rose by 60.2% to full attendance (p less than 0.001). Some of the large amounts of non-emergency food aid available could be offered as incentives to increase the use of basic health services in developing countries.

Adult↗

PubMed2001

A positive analysis of financial incentives for cadaveric organ donation.

Financial incentives of various kinds have been suggested to alleviate the chronic shortage of transplantable organs in the United States. This paper analyzes the possible consequences of financial incentives on organ supply. We show that under current practice and current law (which are not the same), inducements to donate organs or to register as an organ donor may lead to a decline in the supply of organs. Furthermore, some financial incentives that have been proposed lead to time inconsistent choices.

Cadaver↗

PubMed2001

Balancing incentives in the compensation contracts of nonprofit hospital CEOs.

Given the considerable insight into corporate governance achieved through studies of executive compensation in proprietary firms it is surprising that executive contracting in nonprofit organizations remains largely unexplored. In this paper, we use the multitask principal agent model of Holmström and Milgrom [The Journal of Law, Economics and Organization 7 (1991) (Suppl.) 24] to argue that nonprofit hospitals represent an optimal response to information asymmetries between managers and boards. For a board with multidimensional objectives, the agency problem is getting top executives to distribute their efforts across all dimensions of the hospital's mission. The nonprofit form is preferred because the absence of high powered incentives such as share ownership reduces executives' incentives to place undue emphasis on improving financial performance at the expense of important but less observable tasks. Using newly available compensation data we test the model by comparing the conditional distributions of earnings for industrial and nonprofit hospital CEOs in Ontario. Our best estimates are that CEOs in publicly traded firms earn twice as much on average as those in similarly sized nonprofit hospitals but bear roughly eight times the income variance. Estimates of the associated degree of risk aversion are well within conventional bounds and are consistent with the trade-off between insurance and incentives predicted by the theory.

Chief Executive Officers, Hospital↗

PubMed1998

Income-based incentives in UK general practice.

Since 1990, income-based economic incentives have ostensibly become more important in the remuneration structure of UK general practitioners. For incentives to fulfil their role, however, GPs must possess discretion over income-generating activity and be assumed to be income maximisers. Evidence from one English health authority suggests that a very high proportion of GP income continues to be determined by patient characteristics and the scope for a discretionary response to income incentives is correspondingly small. Where discretion does exist, higher levels of GP incomes do not appear to militate against further discretionary income raising, except in the case where this income and budgetary discipline are in conflict.

Analysis of Variance↗

PubMed1989

How do financial incentives affect physicians' clinical decisions and the financial performance of health maintenance organizations?

It has been suggested that the use of financial incentives by health maintenance organizations (HMOs) may change physicians' behavior toward individual patients. To test this hypothesis, we used a regression analysis of data from a survey of HMOs to examine the relation between the presence of financial incentives and two measures of the use of resources (the rate of hospitalization and the rate of visits for outpatient services) and one measure of the HMOs' financial viability (the achievement of break-even status). When we controlled for the effect of market-area variables, we found that some forms of compensation were significantly associated with these indicators of decision making by physicians. Among methods of paying physicians, the use of capitation or salaries was associated with a lower rate of hospitalization than the use of fee-for-service payment; physicians in for-profit HMOs and group-model HMOs also used the hospital less often. Placing physicians at financial risk as individuals and imposing penalties for deficits in the HMO's hospital fund beyond the loss of withheld funds were associated with fewer outpatient visits per enrollee, but a higher percentage of HMO patients in a physician's caseload was associated with more frequent visits. HMOs were more likely to break even if they were larger, older, had physicians who treated more HMO patients, and placed physicians at personal financial risk for the cost of outpatient tests; break-even status was also related to the type of HMO. We conclude that the use of some, but not all, financial incentives, as well as the type of HMO, does influence the behavior of physicians toward patients. It remains to be determined how these factors affect the quality of care.

Decision Making↗

PubMed1990

Physicians' responses to financial incentives. Evidence from a for-profit ambulatory care center.

Health Stop is a major chain of ambulatory care centers operating for profit. Until 1985 its physicians were paid a flat hourly wage. In the middle of that year, a new compensation plan was instituted to provide doctors with financial incentives to increase revenues. Physicians could earn bonuses the size of which depended on the gross incomes they generated individually. We compared the practice patterns of 15 doctors, each employed full time at a different Health Stop center in the Boston area, in the same winter months before and after the start of the new arrangement. During the periods compared, the physicians increased the number of laboratory tests performed per patient visit by 23 percent and the number of x-ray films per visit by 16 percent. The total charges per month, adjusted for inflation, grew 20 percent, mostly as a result of a 12 percent increase in the average number of patient visits per month. The wages of the seven physicians who regularly earned the bonus rose 19 percent. We conclude that substantial monetary incentives based on individual performance may induce a group of physicians to increase the intensity of their practice, even though not all of them benefit from the incentives.

Ambulatory Care Facilities↗

PubMed1985

A work-site weight control program using financial incentives collected through payroll deduction.

In a work-site weight control program using a self-motivational program of financial incentives implemented through payroll deduction, 131 university employees chose weight loss goals (0 to 60 lb) and incentives (+5 to +30) to be deducted from each paycheck for six months. Return of incentive money was contingent on progress toward weight goals. Participants were assigned randomly to one of four protocols, involving group educational sessions v self-instruction only and required v optional attendance at weigh-ins and sessions. Overall, dropout rates (21.4%) and mean weight loss (12.2 lb) were encouraging, especially compared with those of other work-site programs. Weight loss was positively associated with attendance at weigh-ins and educational sessions. However, requiring attendance did not increase program effectiveness and seemed also to discourage enrollment among men. The weight control program was equally effective when offered with professionally led educational sessions or when accompanied by self-instructional materials only.

Adult↗

PubMed1995

The effect of financial incentives on physicians' behaviour in health maintenance organizations.

Examines the relationship between the presence of financial incentives and their effect on physician behavior in health maintenance organizations (HMOs). By reviewing the scope and dimensions of both HMOs and financial incentives, a foundation is laid for the review of the current empirical evidence. Further analysis and conceptual development is given to this topic by stating the limitations of existing research--in the confounding variables, in the complexity of incentives, and in the unanswered questions of quality of care--and by proposing innovative ways of studying the ¿other aspects of physician behavior' not previously considered. Questions and implications are raised for future research and practice.

Capitation Fee↗

PubMed2002

Effects of financial incentives on the breakdown of mutual trust.

Disagreements between psychologists and economists about the need for and size of financial incentives continue to be hotly discussed. We examine the effects of financial incentives in a class of interactive decision-making situations, called centipede games, in which mutual trust is essential for cooperation. Invoking backward induction, the Nash equilibrium solution for these games is counterintuitive. Our previous research showed that when the number of players in the centipede game is increased from two to three, the game is iterated in time, the players are rematched, and the stakes are unusually high, behavior approaches equilibrium play. Results from the present study show that reducing the size of the stakes elicits dramatically different patterns of behavior. We argue that when mutual trust is involved, the magnitude of financial incentives can induce a considerable difference.

Adult↗

PubMed2001

Physician incentives and disclosure of payment methods to patients.

OBJECTIVE: There is increasing public discussion of the value of disclosing how physicians are paid. However, little is known about patients' awareness of and interest in physician payment information or its potential impact on patients' evaluation of their care. DESIGN: Cross-sectional survey SETTING: Managed care and indemnity plans of a large, national health insurer. PARTICIPANTS: Telephone interviews were conducted with 2,086 adult patients in Atlanta, Ga; Baltimore, Md/Washington DC; and Orlando, Fla (response rate, 54%). MEASUREMENTS AND MAIN RESULTS: Patients were interviewed to assess perceptions of their physicians' payment method, preference for disclosure, and perceived effect of different financial incentives on quality of care. Non-managed fee-for-service patients (44%) were more likely to correctly identify how their physicians were paid than those with salaried (32%) or capitated (16%) physicians. Just over half (54%) wanted to be informed about their physicians' payment METHOD: Patients of capitated and salaried physicians were as likely to want disclosure as patients of fee-for-service physicians. College graduates were more likely to prefer disclosure than other patients. Many patients (76%) thought a bonus paid for ordering fewer than the average number of tests would adversely affect the quality of their care. About half of the patients (53%) thought a particular type of withhold would adversely affect the quality of their care. White patients, college graduates, and those who had higher incomes were more likely to think that these types of bonuses and withholds would have a negative impact on their care. Among patients who believed that these types of bonuses adversely affected care, those with non-managed fee-for-service insurance and college graduates were more willing to pay a higher deductible or co-payment in order to get tests that they thought were necessary. CONCLUSIONS: Most patients were unaware of how their physicians are paid, and only about half wanted to know. Most believed that bonuses or withholds designed to reduce the use of services would adversely affect the quality of their care. Lack of knowledge combined with strong attitudes about various financial incentives suggest that improved patient education could clarify patient understanding of the nature and rationale for different types of incentives. More public discussion of this important topic is warranted.

Adult↗

PubMed2003

A comparative assessment of West Virginia's financial incentive programs for rural physicians.

CONTEXT: Financial incentive programs are increasingly being used as a strategy to recruit physicians to underserved rural areas. Critical evaluation of state-supported programs is often lacking but is necessary to determine their efficacy and to improve outcomes. PURPOSE: The purpose of this study was to assess 4 service-contingent programs in West Virginia, a state with critical physician shortages. METHODS: Survey instruments were developed to evaluate the effectiveness of these programs and to document the practice environments and career paths of obligated allopathic and osteopathic physicians compared with a control group of nonobligated rural practitioners. Data were also collected from physicians who were recipients of multiple incentive programs and from obligated physicians who had defaulted. FINDINGS: Responses from more than 60% of surveyed physicians indicated that the typical respondent was a married white male who was a midcareer family practice physician. Obligated physicians were more likely than nonobligated physicians to have graduated from a West Virginia medical school and residency program, to be influenced by financial factors in their career decisions, to provide care to uninsured patients, and to work in offices that offered sliding fee scales. Both groups of physicians demonstrated similar retention patterns, reported a high degree of job satisfaction, and expressed a need for more practice management training. CONCLUSIONS: Although these financial incentive programs were found to be effective in recruiting primary care physicians to medically underserved areas of the state, the financial support of these programs was found to be too modest, and improved marketing of the programs was indicated.

Adult↗

PubMed2001

Using financial incentives to promote shared mental health care.

OBJECTIVES: To consider the most common primary care reimbursement structures, to identify incentives inherent in each, and to discuss how each could be used to encourage a shared-care approach to treating mental disorders at the primary care level. METHOD: Three major financial reimbursement models--fee-for-service, capitation, and blended payment mechanisms--are examined. Each is considered in terms of its risk-sharing elements and the consequent incentives. We offer several scenarios to illustrate how the shared-care practice model might be encouraged under each financing mechanism. RESULTS: The current fee-for-service system does not encourage shared care. For wide adoption of the shared-care practice model, there must be a change in the reimbursement system's incentives. While none of the financing mechanisms offers a perfect solution, each has potential. Each, however, must be carefully tailored to its environment. CONCLUSIONS: Financial considerations are just one aspect to achieving shared care. Nevertheless, in designing a system to encourage collaborative, coordinated care for those suffering from mental illness, decision makers should be wary of creating or maintaining obstacles (financial or otherwise) to provision of accessible, high-quality care.

Canada↗

PubMed2005

The effect of a monetary incentive on return of a postal health and development questionnaire: a randomised trial [ISRCTN53994660].

BACKGROUND: Postal questionnaires are widely used to collect data in healthcare research but a poor response rate may reduce the validity and reliability of results. There was a lack of evidence available relating to use of a monetary incentive to improve the response rate in the healthcare setting. METHODS: The MRC ORACLE Children Study is assessing the health and development of nearly 9000 seven year old children whose mothers' joined the MRC ORACLE Trial. We carried out a randomised controlled trial of inclusion of monetary incentive (five pound voucher redeemable at many high street stores) with the reminder questionnaire to parents. This trial took place between April 2002 and November 2003. When the parents were sent the reminder questionnaire about their child's health and development they were randomly assigned by concealed computer-generated allocation stratified by week of birthday to receive a five pound voucher or no incentive. The population were 722 non-responders to the initial mailing of a 12-page questionnaire. MAIN OUTCOME MEASURES: Difference in response rate between the two groups. RESULTS: Inclusion of the voucher with the reminder questionnaire resulted in a 11.7%(95% CI 4.7% to 18.6%) improvement in the response rate between the two groups. CONCLUSION: This improvement in response rate and hence the validity and reliability of results obtained appears to be justified ethically and financially.

Adult↗

PubMed1993

Using incentives to motivate women to seek prenatal care: an effective outreach strategy.

Expanded Medicaid eligibility and case-managed care have contributed to improved birth outcomes and reduced Medicaid expenditures in Alabama. In 1990, 26.5 percent of all women delayed entry to care until the fourth month of pregnancy or later. Additionally, more than 1,000 women in the state received no care at all. In many of these cases, women perceived prenatal care as unimportant or unnecessary until later in pregnancy. As a result, the Alabama Medicaid Agency developed Healthy Beginnings, an incentive and awareness program which utilizes coupons to motivate women to seek prenatal care. Pregnant women can receive the coupon book (worth about $300) simply by dialing a toll-free number. To take advantage of the free gifts and discounts, expectant mothers must visit a private physician or health clinic and have their coupons validated monthly. The project was initiated in August, 1990, and already there is clear evidence that the use of incentives represents a viable outreach strategy to motivate poor and uninsured women to seek care. In the program's first year, more than 20,000 women received the coupons, of which 78 percent were Medicaid recipients, uninsured or in a presumptive (Medicaid) eligibility period. Focus group studies, field visits and a survey were used to evaluate the effectiveness of the new program. Preliminary data analysis has revealed that the incentive program may be a significant factor in motivating women to seek early and continuous prenatal care.

Alabama↗

PubMedDate not supplied

Disclosing doctors' incentives: will consumers understand and value the information?

As part of a broader movement toward accountability in health care, federal and state governments have required health plans to disclose physicians' financial incentives. Available data suggest that patients have poor comprehension of the incentives and significant barriers to learning, including high trust in their physicians, reluctance to think of the physician/patient relationship in financial terms, and failure to understand the relevance of the information to their health care choices and treatment. Disclosure that conveys clearly what is at stake will increase the salience of incentive information but is also more likely to erode trust.

Attitude to Health↗

PubMed2004

Employee incentive programs.

One great benefit of employee incentive programs is that they connect team compensation with practice performance. Options are always available to keep the incentive programs exciting and motivating. The key is to understand the goal and to put in place the employee incentive program that works for your practice.

Employee Incentive Plans↗

PubMed2005

Prescribing incentive schemes : a useful approach?

INTRODUCTION: From 2000 to 2004, primary care organisations (PCOs) in England were legally required to operate a prescribing incentive scheme for their general practices. A statutory framework specified the types of target, maximum rewards and use of 'good cause for failure' provisions that schemes should include. Our objective was to explore whether schemes might be a useful approach to encourage 'good quality' prescribing. METHODS: We requested copies of the original schemes from all PCOs in England in 2001 and 2002. Data were extracted on the rewards offered, types of budgetary targets set and additional conditions specified. RESULTS: Many schemes had not been finalised, some PCOs had no scheme, and one scheme operated without rewards. Although schemes covered similar therapeutic areas, they varied considerably in their length, complexity, reward levels and reward structure. Over half the schemes contained no 'good cause for failure' provision. DISCUSSION/CONCLUSION: PCOs are offering diverse incentives to general practices and some have interpreted the statutory framework imaginatively. Better use of the 'good cause for failure' provision may help to overcome inflationary pressures on prescribing, but further research is needed to clarify the role of financial incentives in influencing prescribing.

Drug Prescriptions↗

PubMed2001

Capitation and primary care in Canada: financial incentives and the evolution of health service organizations.

Alternative approaches to the funding, organization, and delivery of primary care have been the subject of ongoing discussion and debate in many industrialized nations for many years. One common recommendation has been to use capitation, as opposed to fee-for-service, as the payment method for physicians. In this study the authors use data from interviews with physicians and Ministry of Health officials to trace the evolution of Ontario's Health Service Organization (HSO) program, the only program of capitation-funded physician care in Canada. The program has developed in three phases: formation in the early 1970s, expansion in the late 1970s and throughout the 1980s, and restructuring in the 1990s. The analysis focuses on the perceptions and actions of policymakers and physicians who became involved with the program at different points in its evolution, and identifies how they perceived and responded to the financial incentives that were introduced to promote the program. This case study allows an examination of the shifting objectives, communications, perceptions, and responses of policymakers and stakeholders in changing contexts over a period of more than 20 years. The long history of the HSO program provides the opportunity to examine the factors that can cause financial incentives to go awry. The authors suggest how this case study offers lessons for financial incentive policymaking.

Attitude of Health Personnel↗