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PubMedDate not supplied

Managing risk selection incentives in health sector reforms.

The object of the paper is to review theoretical and empirical contributions to the optimal management of risk selection incentives ('cream skimming') in health sector reforms. The trade-off between efficiency and risk selection is fostered in health sector reforms by the introduction of competitive mechanisms such as price competition or prospective payment systems. The effects of two main forms of competition in health sector reforms are observed when health insurance is mandatory: competition in the market for health insurance, and in the market for health services. Market and government failures contribute to the assessment of the different forms of risk selection employed by insurers and providers, as the effects of selection incentives on efficiency and their proposed remedies to reduce the impact of these perverse incentives. Two European (Netherlands and Spain) and two Latin American (Chile and Colombia) case studies of health sector reforms are examined in order to observe selection incentives, their effects on efficiency and costs in the health system, and regulation policies implemented in each country to mitigate incentives to 'cream skim' good risks.

Economic Competition↗

PubMed2000

Hospital response to DRG refinements: the impact of multiple reimbursement incentives on inpatient length of stay.

Recent research has warned that the introduction of Diagnosis Related Groups (DRGs) based on hospital treatment decisions will lead to an increase in the rate of marginal procedures and to a resumption of high medical expenditure growth rates. This paper explores the often contradictory effects of the multiple reimbursement incentives created by refinements to the Prospective Payment System (PPS) (principally, the introduction of procedure-based DRGs) on hospital resource allocation. Three effects are examined in the paper: (i) the change in primary or payment-related procedures owing to marginal reimbursement incentives; (ii) the change in secondary or non-payment-related services owing to average price incentives; and (iii) the change in average severity of both medical and surgical admissions. The model suggests that the anticipated positive effect of marginal reimbursement incentives on overall hospital resource use may be offset by several factors, most notably the lower average payment incentives of non-procedural DRGs.

Diagnosis-Related Groups↗

PubMed2004

The role of signaling molecules in reward-related incentive learning.

Reward-related incentive learning involves the acquisition by neutral stimuli of an enhanced ability to elicit approach and other responses. Previous studies have shown that both dopamine (DA) and glutamate (Glu) play critical roles in this type of learning. Signaling molecules are intracellular messengers that participate in the influence of transmitter-receptor events on intracellular function including transcription in the nucleus. In recent years studies have begun to implicate signaling molecules in incentive learning. Thus, inhibition of cyclic adenosine monophosphate-dependent protein kinase (PKA) in the nucleus accumbens (NAc), that is activated by DA acting at D1-like receptors, blocks the acquisition of conditioned approach responses, lever pressing for food, conditioned place preference (CPP) based on NAc injections of amphetamine or cocaine, and conditioned activity based on NAc injections of amphetamine. Similar effects have been observed with PKA inhibition in the basolateral amygdala or medial prefrontal cortex. If animals were trained prior to testing with PKA inhibitors in NAc, no effect was seen suggesting that PKA is more important for acquisition than expression of incentive learning. Inhibition of calcium-dependent protein kinase or mitogen-activated protein kinases in NAc similarly has been shown to block the acquisition of incentive learning. Results support a model of DA-Glu synaptic interactions that form the basis of incentive learning.

Animals↗

PubMed2006

Incentive-based conservation programs in developing countries: a review of some key issues and suggestions for improvements.

Biodiversity conservation in developing countries has been a challenge because of the combination of rising human populations, rapid technological advances, severe social hardships, and extreme poverty. To address the social, economic, and ecological limitations of people-free parks and reserves, incentives have been incorporated into conservation programs in the hopes of making conservation meaningful to local people. However, such incentive-based programs have been implemented with little consideration for their ability to fulfill promises of greater protection of biodiversity. Evaluations of incentive-based conservation programs indicate that the approach continually falls short of the rhetoric. This article provides an overview of the problems associated with incentive-based conservation approaches in developing countries. It argues that existing incentive-based programs (IBPs) have yet to realize that benefits vary greatly at different "community" scales and that a holistic conceptualization of a community is essential to incorporate the complexities of a heterogeneous community when designing and implementing the IBPs. The spatial complexities involved in correctly identifying the beneficiaries in a community and the short-term focus of IBPs are two major challenges for sustaining conservation efforts. The article suggests improvements in three key areas: accurate identification of "target" beneficiaries, greater inclusion of marginal communities, and efforts to enhance community aptitudes.

Biodiversity↗

PubMed1992

A multi-level incentive model for service organizations.

Incentive programmes for production employees have been used for many years. However, more recently, there has been an increasing desire to use incentive programmes in service applications, particularly with the advent of electronic performance monitoring. This paper summarizes the methodology for developing a model that incorporates the parameters of quality (customer and supervisor evaluations), quantity of production, sales and individual goals. The model was used to compute incentive bonus payments for customer service employees who performed above standard. Employees were motivated by the incentive bonus, and thus productivity was increased. The model could be applied to any service organization. The model was developed to assist a customer service department where performance standards, quality measures or customer feedback were not firmly established. It measured objectively employee performance and rewarded the employee with individually calculated incentive bonuses through an electronically monitored system. The internal working of the model is a combination of the above parameters. Customized software was used to collect and tabulate customer feedback regarding a recent inquiry to the customer service department. This made up the first part of the quality measure for the department. The second part of the quality parameter was a regular evaluation by the supervisor. The quantity of production was measured by the number of inquiries handled per unit time. Sales were also calculated on a per-unit-time basis. The individual goals were the result of regular employee-supervisor meetings where past and future employee performance was discussed and mutually agreed upon. The five model parameters of quality (customer and supervisor), quantity, sales and individual goals are combined through the use of a linear equation. It was found that this form of employee evaluation worked very well in an electronic monitoring environment and was accepted by the participating work group. Overall, monthly productivity gains exceeded 15%.

Journal Article↗

PubMed1993

Extra-market incentives in the new NHS.

This paper focuses upon a number of features of the NHS reforms which are external to the new market created by the purchaser-provider split. Initially, the market and the problems associated with its operation are examined. Particular consideration is given to the extent to which these problems are likely to hinder the achievement of the Government's objective of improved efficiency in the NHS. Each of the provider, purchaser and consumer sectors of the market is then examined more closely in relation to the extra-market incentives present. It is argued that these incentives do have the potential to complement the purchaser-provider split in encouraging improvements in efficiency. However, in several instances, the incentives are either the wrong incentives or are too weak to have any real impact in changing behaviour. In conclusion, it is argued that there is a need for more direct incentive structures to be introduced if improvements in efficiency are to be realised.

Capital Expenditures↗

PubMed2004

Effects of incentive and preparation time on performance and classification accuracy of standard and malingering-specific memory tests.

The effects of incentive and preparation on performance and classification accuracy of standard and malingering-specific tests were investigated in a simulation study using a 2 (no incentive vs. a $20 incentive) x 2 (immediate vs. delayed preparation) factorial design. Eighty undergraduate students and 15 individuals with traumatic brain injury were administered standard (viz., Digit Span and Visual Memory Span from the WMS-R) and malingering-specific (viz., the Rey 15-Item Memory Test and the Multi-Digit Memory Test) memory tests. Preparation time was found to have a significant effect on performance and classification accuracy on a number of these tests, but incentive was found to have a significant effect on the performance but not the classification accuracy of one test (viz., the Multi-Digit Memory Test). These findings suggest that extra-test variables such as incentive and preparation time should be taken into consideration in evaluating the utility of standard and malingering-specific memory tests in detecting malingering.

Adolescent↗

PubMed2006

Incentive value, unclear task difficulty, and cardiovascular reactivity in active coping.

An experiment with 44 participants assessed the moderating effects of four levels of incentive value on cardiovascular responses in active coping. Randomly assigned to one of four different incentive conditions, participants performed a memory task without knowing its difficulty in advance. By means of successfully performing the task participants could either win no reward, 10 Swiss Francs, 20 Swiss Francs, or 30 Swiss Francs. In accordance with the theoretical predictions derived from motivational intensity theory, reactivity of systolic blood pressure and heart rate monotonically increased with incentive value. Thereby, these findings provide additional empirical evidence for the predictions of motivational intensity theory with regard to unclear task difficulty and extend recent research (Richter, M., Gendolla, G.H.E., 2006. Incentive effects on cardiovascular reactivity in active coping with unclear task difficulty. Int. J. Psychophysiol. 61, 216-225.), which was not conclusive regarding the predicted monotonic relationship between incentive value and cardiovascular reactivity under conditions of unclear task difficulty.

Adaptation, Psychological↗

PubMed1996

Increasing influenza immunization among high-risk patients: education or financial incentive?

PURPOSE: To determine whether an educational brochure or a lottery-type incentive increases influenza immunization rates. PATIENTS AND METHODS: In a prospective, single-blind factorial design randomized trial at an urban community health center, all high-risk patients (n = 797) seen in the preceding 18 months were randomly assigned to one of four groups: a control group; a group mailed a large print, illustrated educational brochure emphasizing factors important to patients in making a decision about influenza immunization; a group mailed a lottery-type incentive announcing that all patients receiving influenza immunization would be eligible for grocery gift certificates; and a group mailed both educational brochure and incentive. Immunization was free, available without an appointment, and recorded by a computerized tracking system. RESULTS: The group mailed the brochure was more likely to be immunized than control (odds ratio [OR] = 2.29, 95% confidence interval [CI] 1.45 to 3.61), as was the group mailed the incentive (OR = 1.68, 95% CI 1.05 to 2.68), but there was no difference between the group mailed both interventions and the control group. The effectiveness of the brochure was more striking for individuals who had not accepted immunization in the prior year (OR = 4.21, 95% CI 2.48 to 7.14), suggesting a true educational effect rather than simply a reminder. CONCLUSION: In this community health center setting, an illustrated educational brochure increased influenza immunization among high-risk patients, a lottery-type incentive was much less effective, and both together was not effective.

Aged↗

PubMed2002

Smoking, reward responsiveness, and response inhibition: tests of an incentive motivational model.

BACKGROUND: Incentive-motivation models of addiction suggest impairment of functional activity in mesocorticolimbic reward pathways during abstinence. This study tested implications for subjective and behavioral responses to nondrug incentives, cue-elicited craving, and prefrontal cognitive functions, particularly response inhibition. METHODS: We tested 26 smokers after smoking and after overnight abstinence in counterbalanced order; 26 nonsmokers were also tested twice. Measures included a simple card-sorting test performed with and without financial incentive (the CARROT), the Snaith Hamilton Pleasure Scale as an index of subjective reward responsiveness, ratings of subjective craving and withdrawal before and after exposure to a cigarette, an index of oculomotor response inhibition (saccadic vs. antisaccadic eye movements), verbal fluency, and reversed digit span. RESULTS: Compared with the smoking condition, and independently of withdrawal severity, abstinence was associated with reduced cue reactivity, pleasure expectancies, responsiveness to financial incentive, and response inhibition (antisaccadic eye movements). Verbal fluency and reversed digit span were unaffected, contrary to findings elsewhere with heavier smokers. Nonsmokers' scores either fell between those of abstainers and recent smokers or approximated those of recent smokers. CONCLUSIONS: The data were in general consistent with behavioral predictions derived from the incentive-motivational model of addiction and suggest that abstinence may be associated with impairments of motivation and response inhibition, which are independent of other subjectively experienced withdrawal symptoms.

Adolescent↗

PubMed1997

Dialysis patient attitudes toward financial incentives for kidney donation.

Offering financial incentives to families of brain-dead individuals has been proposed as a way to increase the supply of organs for transplantation. However, such incentives may lead to weakening of altruism and exploitation of poor families. We investigated dialysis patient attitudes toward the potential benefits and problems of incentives. Using a structured questionnaire, we interviewed 60 randomly selected patients at three chronic hemodialysis units. Subjects were asked to make an explicit trade-off between maintaining altruism versus increasing the supply of kidneys. They were also asked to make a trade-off between protecting poor families versus increasing the supply of kidneys. In addition, we asked subjects how they thought incentives would affect donation by different types of families. We found that 37% of all subjects placed more emphasis on maintaining altruism, 42% placed more emphasis on increasing the supply of kidneys, and 22% placed an equal emphasis on maintaining altruism and on increasing the supply of kidneys. Similarly, 35% of all subjects placed more emphasis on protecting poor families, 33% placed more emphasis on increasing the supply of kidneys, and 32% placed an equal emphasis on protecting poor families and on increasing the supply of kidneys. Subjects thought financial incentives would greatly increase donation by poor families while having little impact on rich families. In conclusion, even though dialysis patients are likely to benefit from increasing the supply of kidneys, many of them want to maintain altruism and protect poor families even if that means fewer kidneys. These concerns should be addressed in proposals to modify the transplant system.

Adolescent↗

PubMed1999

The effects of lottery incentive and length of questionnaire on health survey response rates: a randomized study.

Maximizing the response rate of self-administered questionnaires is key in survey research. We aimed to evaluate the effects of lottery incentive and length of questionnaire on health survey response rates when used in isolation or combined. A random sample of 440 residents in Western Sydney, Australia was randomly allocated to four equal groups to receive or not receive an instant lottery ticket and a long (seven page) or short (one page) questionnaire. The overall response rate was 71.8%. The final response rates were higher among those receiving the short, rather than the long, questionnaire (75.6% versus 68.2%) (P = 0.08); and among those receiving the lottery incentive compared with those not receiving the incentive (75% versus 68.2%) (P = 0.09). By logistic regression analysis, the success of obtaining a completed questionnaire without any follow-up reminders was significantly associated with the lottery incentive but not the questionnaire length (P = 0.03 and P = 0.54, respectively). The difference between lottery and no lottery groups decreased gradually during the follow-up. A lottery incentive is associated with an increased response after the first mailing. A small up-front cost for a lottery ticket may be worthwhile, since it can save further costs by obviating the need for repeated follow-ups.

Australia↗

PubMed2000

Effects on subject response of information brochures and small cash incentives in a mail-based case-control study.

PURPOSE: To investigate the impact on subject response of an information brochure and cash incentives included with mailed questionnaires in case-control studies. METHODS: A randomized trial was carried out within a case-control study investigating cancer in the Province of Ontario. Brochures were included with half of the mailed questionnaires sent to 7487 cases and 2561 controls. Controls were also sent cash incentives of $2, $5, or no money. RESULTS: With the brochure, response changed from 75.0% to 75.8% in cases, and from 70.3% to 71.1% in controls. Adjusting for differences in age, residence, sex, and cancer site/status, the change was 0.2% [95% confidence interval (CI) = -1.7-2.1] in cases, and 0.6% (95% CI = -3.1-4.3) in controls. The $2 and $5 incentives increased overall response in controls from 61.9% to 72.8% and 77.2%, respectively, i.e., by 10.9% (95% CI = 6.1-15.6) and 15.1% (95% CI = 10.4-19.7), after adjustment. This effect was largely confined to urban areas (for $2 and $5, respectively: 5.5% and 14.2% in Toronto, 15.3% and 20.4% in other urban areas vs. 2.7% and 1.0% in rural areas; p = 0.02). Response time showed little or no improvement when the brochure was included, but was markedly reduced for both the $2 and $5 incentives. CONCLUSIONS: Cash incentives can improve subject response in epidemiologic studies, whereas information brochures do not appear to have an effect.

Adult↗

PubMed1984

Effect of extrinsic incentives on use of test anxiety as an anticipatory attributional defense: playing it cool when the stakes are high.

We conducted an experiment to assess the effect of extrinsic incentives on the use of test anxiety as a self-handicapping strategy. We hypothesized that although reports of anxiety may be greater when such symptoms can serve a defensive function, this effect occurs only when extrinsic incentives are low and not under conditions of high extrinsic incentive. Eighty-four male undergraduates anticipated taking a test of intellectual abilities and either were led to believe that test anxiety has no effect on test performance or were given no particular information about the relation between test anxiety and performance. Subjects were offered either +5 or +25 for obtaining the highest score on the test. Consistent with predictions, no-information subjects reported greater test anxiety before the test than did those who believed that test anxiety was unrelated to performance, but only when the extrinsic incentive for performance was low. However, these subjects did not report greater cognitive interference or exhibit lower test scores than did subjects in other conditions. It is tentatively suggested that the defensive strategy used by these subjects consisted of altering perceptions of anxiety, rather than anxiety itself. The implications of the absence of self-handicapping under high incentive conditions are discussed.

Anxiety↗

PubMed2002

The brief abstinence test: effects of continued incentive availability on cocaine abstinence.

This study compared the effects of 4 voucher incentive conditions of a brief abstinence test on continuous cocaine abstinence. In 3 conditions, cocaine-abusing methadone patients could earn $100 for 2 days of cocaine abstinence; 2 of these conditions offered, on either a continuous or interrupted schedule, an additional $300 for evidence of sustained abstinence over the next 9 days. In the 4th condition, no incentives were available. In incentive conditions, 70-80% of patients initiated abstinence, compared with 48% in the no-incentive condition. Both continuing reinforcement conditions produced higher rates of sustained abstinence than the single and no-voucher conditions. The study confirmed the utility of quantitative urine-testing methods combined with high valued incentives to promote cocaine abstinence initiation in methadone maintenance patients.

Adult↗

PubMed1999

Cocaine self-administration increases the incentive motivational properties of the drug in rats.

A progressive increase in the frequency and intensity of drug use is one of the major behavioural phenomena characterizing the development of addiction. The nature of the drug-induced adaptations involved in this escalating drug intake remains unknown. Some theories propose that this escalation is due to a progressive decrease (tolerance) in the reinforcing or incentive effects of the drug. Alternative views posit that with chronic use the reinforcing or incentive effects of drugs increase, by a sensitization or a learning mechanism. In this report, we address the question of whether escalating cocaine intake is paralleled by an increase or a decrease in the reinforcing and incentive effects of the drug. Using the experimental model of intravenous drug self-administration with a within-session dose-response paradigm, we first studied the course of cocaine intake over 14 sessions in rats. After acquisition of cocaine self-administration, cocaine intake progressively increased at each dose tested. Then rats, previously allowed to self-administer cocaine during either six or 29 sessions, were compared in three different tests of the incentive and reinforcing effects of cocaine: cocaine-induced reinstatement of self-administration, cocaine-induced runway and cocaine-induced place conditioning. As compared with rats briefly exposed to cocaine self-administration (six sessions), rats with the longer experience (29 sessions) exhibited a higher intake of cocaine paralleled by a higher responsiveness in the cocaine-induced reinstatement and runway tests. Both groups of rats were similarly sensitive to the rewarding effects of the drug as evaluated by the threshold dose of cocaine inducing place conditioning. Our results demonstrate that escalating cocaine intake is paralleled by an increase in the motivational properties of the drug in the absence of apparent signs of tolerance to the reinforcing or incentive effects of cocaine.

Animals↗

PubMed2001

Repeat whole-blood and plateletpheresis donors:unreported deferrable risks, reactive screening tests, andresponse to incentive programs.

BACKGROUND: Evaluating plateletpheresis (PPH) and repeat community whole-blood (RWB) donors' responses to donation incentive programs is essential for developing effective donor retention programs. STUDY DESIGN AND METHODS: Using data from a 1998 anonymous questionnaire sent to 92,581 US blood donors, the prevalence of unreported deferrable risks, screening test reactivity, and response to incentives were compared in RWB and PPH donors by the use of weighted chi-square tests and logistic regression analyses. RESULTS: From 52,650 respondents, 38,884 RWB and 2,028 PPH donors were identified. Levels of screening test reactivity (1%) and unreported deferrable risks (UDRs, 2-3%) were similar in RWB and PPH donors. RWB and PPH donors were strongly encouraged or discouraged by similar incentives. Of the incentives that would encourage a higher proportion of UDR-free RWB donors to return, cholesterol screening and earning a blood credit appealed to >50 percent. Similar results were obtained for cholesterol screening in PPH donors. Community service or education credits, premarital screening, and cash had limited appeal for PPH and RWB donors, respectively, and would be more likely to differentially encourage donors with a UDR to return. CONCLUSION: Incentives that were associated with the greatest donor appeal and that minimized the potential recruitment of more risky donors were identified.

Adult↗

PubMed2000

The psychology and neurobiology of addiction: an incentive-sensitization view.

The question of addiction specifically concerns (1), the process by which drug-taking behavior, in certain individuals, evolves into compulsive patterns of drug-seeking and drug-taking behavior that take place at the expense of most other activities and (2), the inability to cease drug-taking; the problem of relapse. In this paper current biopsychological views of addiction are critically evaluated in light of the "incentive-sensitization theory of addiction", which we first proposed in 1993, and new developments in research are incorporated. We argue that traditional negative reinforcement, positive reinforcement, and hedonic accounts of addiction are neither necessary nor sufficient to account for compulsive patterns of drug-seeking and drug-taking behavior. Four major tenets of the incentive-sensitization view are discussed. These are: (1) Potentially addictive drugs share the ability to produce long-lasting adaptations in neural systems. (2) The brain systems that are changed include those normally involved in the process of incentive motivation and reward. (3) The critical neuroadaptations for addiction render these brain reward systems hypersensitive ("sensitized") to drugs and drug-associated stimuli. (4) The brain systems that are sensitized do not mediate the pleasurable or euphoric effects of drugs (drug "liking"), but instead they mediate a subcomponent of reward we have termed incentive salience (drug "wanting"). We also discuss the role that mesolimbic dopamine systems play in reward, evidence that neural sensitization happens in humans, and the implications of incentive-sensitization for the development of therapies in the treatment of addiction.

Animals↗