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PubMed1989

Capitation dentistry: incentives and implications.

Capitation is an incentive-based form of payment for dental care. Unlike fee-for-service benefit plans, the nature of reimbursement in capitation plans provide dentists with the necessary incentives to perform appropriate and necessary level of care, seek less costly but effective alternatives, and place an emphasis on prevention. This paper examined how some of these incentives work and their effects on the practice of dentistry.

Capitation Fee↗

PubMed1995

The impact of physician financial incentives on high-risk populations in managed care.

The challenge of managed care is to design a system in which rules and incentives together create a system of checks and balances that ensure both efficient and high-quality care. Incentives need to be administered so that physicians--both primary care providers and specialists--are not forced to choose between personal and/or organizational financial viability and patients' care. To accomplish this goal, payment needs to be linked both to quality and productivity and appropriately risk-adjusted. Quality assurance programs must ensure that both efficient and high-quality care is being provided and must maintain the satisfaction of both physicians and members. AIDS patients may be harmed by a system in which the more services a physician performs, the more he or she is paid--the traditional way in which American health care has been delivered heretofore. Managed care may undermine the care of high-risk patients if it arbitrarily reduces the high volume of care they require. However, a managed care system with effective checks and balances on financial incentives and quality of care can ensure that an efficient and high standard of care is being met--across all populations, including both healthy and high-risk patients.

Acquired Immunodeficiency Syndrome↗

PubMed2000

Primary care physician incentives in medical group practices.

CONTEXT: Although medical groups are adapting to changes in financing health care, little is known about individual physician incentives in this environment. OBJECTIVES: To describe methods group practices use to compensate primary care physicians in a managed care environment and to examine the association of revenue sources for the group practice from all patients and primary care physician incentives. DESIGN: We surveyed by mail group practice administrators for practices that had at least 200 members continuously enrolled in 1995. SETTING: Group practices that had contractual arrangements with Blue Cross/Blue Shield of Minnesota. PARTICIPANTS: One hundred of 129 group practices returned usable surveys. RESULTS: Most groups had some portion of primary care physicians' compensation at risk, although 17 groups compensated them through fully guaranteed annual salary. Seventy-one groups used productivity, 4 groups used quality of care, 1 group used utilization, and 30 used group financial performance. Factors reported to significantly influence primary care physician compensation included billings or charges, overall group practice performance, and net revenue or profit. Groups that had a higher proportion of income from various types of fee-for-service arrangements used lower proportions of base salary for primary care physician compensation and were more likely to relate physician income to measures of productivity. CONCLUSIONS: Substantial variation exists in the types of primary care physician incentives implemented by medical groups. Base salary, individual productivity, and group financial performance were most frequently used to determine compensation. Physician personal financial risk was higher overall in group practices that derived more revenue from fee-for-service contracts.

Adult↗

PubMed2000

FMRI visualization of brain activity during a monetary incentive delay task.

Comparative studies have implicated striatal and mesial forebrain circuitry in the generation of autonomic, endocrine, and behavioral responses for incentives. Using blood oxygen level-dependent functional magnetic resonance imaging, we sought to visualize functional activation of these regions in 12 normal volunteers as they anticipated and responded for monetary incentives. Both individual and group analyses of time-series data revealed significant activation of striatal and mesial forebrain structures (including insula, caudate, putamen, and mesial prefrontal cortex) during trials involving both monetary rewards and punishments. In addition to these areas, during trials involving punishment, group analysis revealed activation foci in the anterior cingulate and thalamus. These results corroborate comparative studies which implicate striatal and mesial forebrain circuitry in the elaboration of incentive-driven behavior. This report also introduces a new paradigm for probing the functional integrity of this circuitry in humans.

Adult↗

PubMed1980

Incentives to enhance the effects of electromyographic feedback training in stroke patients.

The use of monetary incentives to enhance the effects of electromyographic (EMG) feedback training was studied in five stabilized stroke patients with hemiplegia. The study was divided into Baseline, EMG Feedback Training, Feedback Training Plus Incentives, and Follow-up treatment conditions. Integrated EMG activity was recorded simultaneously from the anterior tibialis and medial gastrocnemius muscles during relaxation and dorsiflexion of the affected foot. Patients were instructed to try to increase anterior tibialis EMG activity while decreasing EMG activity in the medial gastrocnemius. Range of motion was measured both prior to and immediately following the Baseline and Feedback Training conditions. Results suggested that (a) EMG feedback training produced greater EMG control and range of motion than did unassisted practice, and (b) the addition of monetary incentives may enhance the effects of feedback training, possibly through its effect on patient motivation.

Adult↗

PubMed1976

Effectiveness of college students in an incentive community program for chronic hospitalized patients.

The study describes and assesses an incentive community program implemented by college students for all of the chronic hospitalized patients living in a locked ward. Behavioral ratings of ward behavior and discharge rates were significantly higher for the experimental than for matched control patients. Bed-wetting was eliminated in 70% of the bed-wetting patients. Students rated the incentive community program more effective in changing the behavior of patients than students' ratings of a case-aide program. No differences in patient behaviors were found between the incentive community and case-aide program.

Behavior Therapy↗

PubMed1993

Response outcomes affect the retention of behavioral tolerance to alcohol: information and incentive.

Twenty-four male undergraduates acquired tolerance during three sessions where they received moderate doses of alcohol (0.62 g/kg) and repeatedly performed a motor skill task with immediate knowledge of results (KR) on each trial. Subjects were assigned to one of four groups (n = 6) before a retention test session where two groups received alcohol and two expected alcohol but received a placebo. The effect on tolerance retention of withholding KR was tested in alcohol group A. The effect of an incentive in the absence of KR was examined in the other alcohol group (AM) that was offered a delayed monetary reward for nonimpaired performance. Both alcohol groups failed to retain tolerance and their impairment did not differ. The effect of substituting the incentive for KR on a drug-compensatory response to placebo was examined in group PM by comparing its performance to group PC where KR was continued. A compensatory response (i.e., performance superior to drug-free baseline) was displayed by the PC group but not by group PM. Thus, despite a monetary incentive to perform well, tolerance to alcohol and a compensatory response to placebo were both disrupted by withholding KR. The results were interpreted in terms of the information about performance conveyed by KR.

Adult↗

PubMed1999

Incentives and accessibility: a pilot study to promote adherence to TB prophylaxis in a high-risk community.

SETTING: A community-based directly observed preventive therapy (DOPT) program for treatment of latent tuberculosis infection among injection drug users (IDUs) in an inner-city neighborhood. OBJECTIVE: To test adherence to a 6-month course of DOPT using cash incentives and an easily accessible neighborhood location. DESIGN: Street-recruited IDUs (N = 205) were screened for Mycobacterium tuberculosis (TB) infection using the Mantoux test and two controls. Subjects who had a purified protein derivative (PPD) reaction of > or =5 mm, were anergic, or had a history of a positive PPD received clinical evaluation at a community field site, provided in collaboration with the San Francisco Department of Public Health Tuberculosis Clinic. Twenty-eight subjects were considered appropriate candidates for prophylaxis with isoniazid, and 27 enrolled in the pilot study. Participants received twice-weekly DOPT at a community satellite office, with a $10 cash incentive at each visit. RESULTS: The 6-month (26-week) regimen was completed by 24/27 (89%) participants. The median time to treatment completion was 27 weeks (range 26 to 34 weeks). The median proportion of dosing days attended in 6 months was 96%. CONCLUSION: Community-based DOPT using cash incentives resulted in high levels of adherence and treatment completion among drug users.

Adult↗

PubMed1977

The Bartlett-Edwards incentive spirometer: a preliminary assessment of its use in the prevention of atelectasis after cardio-pulmonary bypass.

A preliminary assessment of the effectiveness of the Bartlett-Edwards incentive spirometer was made using it as part of the post-operative treatment of 34 patients after open-heart surgery. Its effects on atelectasis were assessed by measuring vital capacity, arterial oxygen tensions, clinical signs and radiological changes. It was found that vital capacity fell after surgery to 41.5 per cent of the pre-operative level, but this rose after the use of the incentive spirometer by an average of 15.5 per cent. Arterial oxygen tensions were unaltered by the use of the incentive spirometer. Temperature, pulse and respirations were of little help in the early diagnosis of atelectasis, but all patients who were still pyrexic four days after operation showed radiological evidence of atelectasis. The incidence of atelectasis demonstrated radiologically was total 84 per cent and plate 69 per cent, sub-segmental 34 per cent and segmental 9 per cent. The implications of these findings are discussed.

Adult↗

PubMed1980

Incentive spirometry: its value after cardiac surgery.

Treatment with intermittent positive pressure breathing (IPPB) and incentive spirometry (I.S.) was compared in 109 patients after heart surgery with cardiopulmonary bypass. Assessment was done by measurement of vital capacity, arterial oxygen tension and identification of the radiological signs of atelectasis. All patients were instructed pre-operatively in the treatment which was to be used. Vital capacity, arterial oxygen tension while breathing air for the first three postoperative days and the incidence of atelectasis showed no significant difference between groups. Ten minutes after treatment the arterial oxygen tension fell, but this was only statistically significant after I.P.P.B. At 60 minutes the arterial oxygen tension had returned to pretreatment level in both groups. The use of the incentive spirometer four times daily is no better than I.P.P.B., in preventing atelectasis after open-heart surgery. Possibly incentive spirometer treatment given more frequently may be more effective.

Cardiopulmonary Bypass↗

PubMed2002

A tale of two countries: costs and financial incentives for provisional stenting during percutaneous coronary intervention in France and the United States.

Provisional stenting is associated with longer physician time but the use of fewer stents. This randomized controlled trial in tertiary care in French hospitals compared strategies of systematic and provisional stenting. We estimated the costs and financial incentives associated with each strategy, based on individual data on 12-month resource use drawn from a 251-patient database. Resources were evaluated using French costs; data on costs in the United States were drawn from the literature and interviews with hospital administrators in one center. In France 1-year costs were 8,267+/-528 dollars for provisional stenting and 7,973+/-553 dollars for systematic stenting, compared to 18,715 dollars and 18,632 dollars in the United States. Given the uncertainty of longterm results, the choice between stenting strategies might be guided by financial incentives. In the United States financial incentives favor systematic stenting, while in France public hospitals and physicians are neutral.

Clinical Trial↗

PubMed1991

Incentive spirometry versus routine chest physiotherapy for prevention of pulmonary complications after abdominal surgery.

We entered 876 patients into a clinical trial aimed at preventing pulmonary complications after abdominal surgery. Patients either received conventional chest physiotherapy or were encouraged to perform maximal inspiratory manoeuvres for 5 min during each hour while awake, using an incentive spirometer. The incidence of pulmonary complications did not differ significantly between the groups: incentive spirometry 68 of 431 (15.8%, 95% CI 14.0-17.6%), and chest physiotherapy 68 of 445 (15.3%, CI 13.6-17.0%). Nor was there a difference between the groups in the incidence of positive clinical signs, pyrexia, abnormal chest radiographs, pathogens in sputum, respiratory failure (PO2 less than 60 mm Hg), or length of stay in hospital. We conclude that prophylactic incentive spirometry and chest physiotherapy are of equivalent clinical efficacy in the general management of patients undergoing abdominal surgery.

Abdomen↗

PubMed1995

Agency and incentives in the NHS internal market.

This paper presents and assesses the structure of incentives created by the 1991 reforms to the U.K. National Health System. It argues that these reforms created a set of overlapping principal-agent relationships, in which the ownership of assets and the division of rewards from use of these assets is unclear. This lack of clarity and the form of performance monitoring used by the government as principal in these agency relationships seem likely to give limited incentives for improvements in efficiency in the medium term. The paper discusses possible means to improve incentives.

Economic Competition↗

PubMedDate not supplied

Event-related brain potentials to high incentive stimuli in abstinent alcoholics.

We have previously found that the P3 component of the event-related potential (ERP) is reduced in alcoholics in visual target-selection paradigms. P3 voltage depends on the "subjective significance" of the stimulus (e.g., task relevance, probability of occurrence, motivational factors). We were interested in assessing P3s in alcoholics to motivationally significant stimuli that did not differ with respect to other aspects of significance. Equiprobable, task-relevant visual stimuli with different acquired incentive values were presented to alcoholics under baseline and two incentive conditions. Alcoholics manifested similar lower P3 voltages without P3 latency delays to all stimuli, regardless of incentive values. Latency Corrected Averages indicated that these results were not due to latency jitter in the averages. These results suggest multiple system deficits in alcoholics, perhaps in involving frontal and/or medial temporal lobe, the brain sources implicated in the generation of P3. Our results perhaps reflect a deficit in motivational-cognitive systems in alcoholics, possibly affecting their ability to actively sustain information processing.

Adolescent↗

PubMed2006

The attribution of incentive salience to a stimulus that signals an intravenous injection of cocaine.

A central premise of a number of theories of addiction is that discrete environmental stimuli repeatedly paired with drugs of abuse acquire incentive salience as a result of Pavlovian learning. There is, however, no unequivocal evidence supporting this assumption. Thus, we employed a Pavlovian conditioning procedure known to imbue non-drug reinforcers with incentive salience and extended it to study the effects of intravenous cocaine. Specifically, we examined whether a cue paired with intravenous cocaine administration would come to elicit approach towards it (sign-tracking), even if no behavioral response were required to receive the cue or drug. We found that when a cue was paired with intravenous cocaine delivery (but not when it was unpaired) rats came to approach and investigate the cue, and did so with increasing rapidity. We conclude that Pavlovian learning can imbue drug-paired cues with incentive salience, making them attractive and "wanted" stimuli. Delineating the neurobiological mechanisms responsible for this process will be important for understanding and treating drug addiction.

Analysis of Variance↗

PubMed2005

Incentive effects on cardiovascular reactivity in active coping with unclear task difficulty.

Two experiments with a total of 96 participants assessed cardiovascular response in active coping. The studies were run in 2x2 designs and manipulated the clarity of task difficulty (clear vs. unclear) and incentive value (low vs. high) of a memory task, which was either easy (Experiment 1) or extremely difficult (Experiment 2). In accordance with the theoretical predictions of motivational intensity theory [Brehm, J.W., Self, E.A., 1989. The intensity of motivation. Annu. Rev. Psychol. 40, 109-131; Wright, R.A., 1996. Brehm's theory of motivation as a model of effort and cardiovascular response. In: Gollwitzer, P.M., Bargh, J.A. (Eds.), The Psychology of Action: Linking Cognition and Motivation to Behaviour, Guilford, New York, pp. 424-453], systolic reactivity varied directly with incentive value when task difficulty was unclear. In contrast, when task difficulty was clear, incentives had no influence and cardiovascular reactivity was low. These findings provide the first evidence for the predictions of motivational intensity theory with regard to unclear task difficulty and complete past research that has focused on the effects of fixed and unfixed task difficulty on cardiovascular reactivity.

Adaptation, Psychological↗

PubMed2006

Nutrient-conditioned flavor preference and incentive value measured by progressive ratio licking in rats.

Rats develop strong preferences for flavors associated with the postingestive actions of glucose and other nutrients. This preference may involve changes in both the hedonic appeal and incentive salience of the nutrient-paired flavor. The present study used a progressive ratio (PR) operant licking task to evaluate the degree to which nutrient conditioning changes the incentive value of flavors. Food restricted rats were trained to associate one flavored saccharin solution (CS+) with intragastric glucose infusions and another flavored solution (CS-) with water infusions. The rats subsequently showed a strong preference for the CS+ in two-bottle tests and also licked more for the CS+ than CS- in PR tests. PR licking for the CS+ was similar to that for an 8% fructose solution. Together with earlier data indicating that the CS- is isopreferred to a 3% fructose solution, these findings indicate that IG glucose conditioning enhances the hedonic and incentive value of the CS+ solution so that the animal responds as if the solution had a sweeter taste.

Animals↗

PubMed1997

Effects of incentive programs to stimulate safety belt use: a meta-analysis.

The effects of campaigns using tangible incentives (rewards) to promote safety belt usage have been evaluated by means of a meta-analytic approach. Two coders extracted a total number of 136 short-term and 114 long-term effect sizes and coded many other variables from 34 journal articles and research reports. The results show a mean short-term increase in use rates of 20.6 percentage points; the mean long-term effect was 13.7 percentage points. Large scale studies report smaller effect sizes than small scale studies; when studies were weighted by the (estimated) number of observations, the weighted mean effect sizes were 12.0 and 9.6 percentage points for the short and long term, respectively. The main factors that influence the magnitude of the reported short-term effect of the programs were the initial baseline rate (which was highly correlated with the presence or absence of a safety belt usage law), the type of population involved, whether incentives were delivered immediately or delayed, and whether incentives were based on group or individual behaviour. Together these four variables accounted for 64% of the variance. Other variables, such as the duration of the intervention, the probability of receiving a reward, and the value of the reward were not related to the short-term effect sizes. The relationship between moderating variables and long-term effects was less clear.

Humans↗