Economic incentives and physicians’ delivery of preventive care: A systematic review

doi:10.1016/j.amepre.2004.10.013

American Journal of Preventive Medicine

Volume 28, Issue 2, February 2005, Pages 234-240

https://doi.org/10.1016/j.amepre.2004.10.013 Get rights and content

Abstract

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.

Introduction

Increasing preventive care is widely held to be a cost-effective way to improve population health. This belief, which lays the foundation for preventive care—measured as targets in public health initiatives (e.g., Healthy People 2010),¹ and even codified in the Hippocratic oath—has empirical support. Yet, many cost-effective preventive services are under-provided.2, 3 Underlying this puzzling fact are two interrelated public health questions. First, if many prevention efforts are cost-effective, why are they under-delivered? Second, what interventions can increase the amount of cost-effective preventive care?

Of the many potential causes for the under-provision of preventive care, this paper focuses on the possibility that practicing physicians lack the necessary financial incentives for providing preventive care. If true, this suggests that one potential solution to the public health problem of the under-provision of preventive care lies in restructuring physician incentives. This paper reviews the randomized trial literature examining the impact of financial incentives on provider preventive care delivery, evaluating the evidence on the impact of explicit economic incentives targeted at motivating physicians to provide preventive health services and support consumer preventive health behavior change. This review is designed to (1) assist in the development of more effective preventive strategies (evidence-based practice), and (2) inform key stakeholders about the role of such practices (evidence-based policymaking).

This review focuses solely on the randomized trial literature and does not directly assess the impact of HMOs and other managed care organization risk-sharing, payment, and pricing mechanisms as compared to fee-for-service (FFS) mechanisms. While there is considerable interest in the effects of these larger, general economic incentives, the focus here is on explicit economic incentives for preventive care. The potentially numerous confounding factors derived from different patient populations and physician populations, and structures and processes of different systems might overwhelm the potential usefulness of a review of explicit incentives.⁴

Section snippets

Definition of prevention

For purposes of this review, preventive care and health promotion are defined as those circumstances where consumers may consider themselves healthy or physically at risk, but not yet labeled with a diagnosis. This definition includes individual-based health promotion and preventive services as defined in Healthy People 2000⁵ and Healthy People 2010,¹ but excludes mental health, substance abuse, and health protection concerns, such as injury prevention, occupational health and safety,

Results

Only six studies met the inclusion criteria. These six studies, summarized in Table 1, generated eight separate outcomes. Two studies7, 8 analyzed two interventions each (FFS and bonus). Four articles examined immunizations, two looked at cancer screening, and one looked at an assortment of preventive services. These figures do not add to six (the number of studies) because two studies used more than one preventive care measure as an outcome. Only one of the eight results⁹ found that increasing

Discussion

This analysis suggests several conclusions. First, and perhaps most important, the literature is very sparse. Only six studies met the inclusion criteria. This suggests that future well-conceived studies could make a significant contribution to our state of knowledge. Second, only one of the findings found a significant link between financial incentives and the provision of preventive care. The lack of a significant relationship should not be interpreted as implying that financial incentives

References (19)

A.B. Coffield et al.
Priorities among recommended clinical preventive services
Am J Prev Med
(2001)
R.P. Harris et al.
Current methods of the U.S. Preventive Services Task Forcea review of the process
Am J Prev Med
(2001)
G. Fairbrother et al.
Impact of financial incentives on documented immunization rates in the inner cityresults of a randomized controlled trial
Ambul Pediatr
(2001)
R.W. Kouides et al.
Performance-based physician reimbursement and influenza immunization rates in the elderlythe primary-care physicians of Monroe County
Am J Prev Med
(1998)
K.E. Grady et al.
Enhancing mammography referral in primary care
Prev Med
(1997)
J.R. Lave et al.
Participation in health promotion programs by the rural elderly
Am J Prev Med
(1995)
B. Gray
Do Medicaid physician fees for prenatal services affect birth outcomes?
J Health Econ
(2001)
Healthy People 2010
(2000)
T.O. Tengs et al.
Five hundred life-saving interventions and their cost-effectiveness
Risk Analysis
(1995)

There are more references available in the full text version of this article.

Cited by (101)

Effect of financial incentives on breast, cervical and colorectal cancer screening delivery rates: Results from a systematic literature review
2019, Health Policy
Preventive care, such as screening, is important for reducing the risk of cancer, a leading cause of death worldwide. Indeed, some type of cancers are detected through screening programs, which in most countries run for colorectal, breast, and cervical cancers. In this context, general practitioners play a key role in increasing the participation rate in cancer screening programs. To improve cancer screening delivery rates, performance incentives have increasingly been implemented in primary care by healthcare payers and organizations in different countries. The effects of these tools are still not clear.
We conducted a systematic literature review in order to answer the following research question: What is the evidence in the literature for the effects of financial incentives on the delivery rates of breast, cervical and colorectal cancer screening in general practice?
We performed a literature search in Web of Science, PubMed, Cochrane Library and Google Scholar, according to the PRISMA guidelines. 18 studies were selected, classified and discussed according to the health preventive services investigated.
Most of studies showed partial or no effects of financial incentives on breast and cervical cancer screening delivery rates. Few positive or partial effects were found regarding colorectal cancer screening.
Ongoing monitoring of incentive programs is critical to determining the effectiveness of financial incentives and their effects on the improvement of cancer screening delivery rates.
Details matter: Physician responses to multiple payments for the same activity
2019, Social Science and Medicine
Citation Excerpt :
These include Australia (Scott, 2007), Canada (Pink et al., 2006), Germany (Greb et al., 2006), the Netherlands (Custers et al., 2006), New Zealand (Perkins and Seddon, 2006), Spain (Gené-Badia et al., 2007), the UK (Meacock et al., 2014), and the US (Rosenthal et al., 2006). They have had mixed success (Guthrie and Tang, 2016; Gillam et al., 2012; Scott et al., 2011; Van Herck et al., 2010; Greene and Nash, 2009; Christianson et al., 2007; Petersen et al., 2006; Town et al., 2005; Armour et al., 2001). Both standard and behavioural economic models suggest that the design of P4P schemes matters in the sense that it will change the behaviour of those incentivised, not just the rewards they receive (Eijkenaar et al., 2013; Kristensen et al., 2013; Mehrotra et al., 2010).
The UK Quality and Outcomes Framework rewards general practices for achieving quality indicators for chronic disease management. Some indicators are multi-rewarded. For example, there are indicators for controlling blood pressure for patients with diabetes and for patients with chronic heart disease. Thus if a patient has diabetes and heart disease the practice is rewarded twice for controlling her blood pressure. Other indicators are singly rewarded: the incentivised activity is only for patients with single specific condition. We compare general practice performance on single and multi-reward indicators. We use a 2005/6–2012/13 panel of over 800 Scottish general practices, control for practice characteristics, practice fixed effects, indicator characteristics (whether the indicator was for measurement, treatment, or intermediate outcome, maximum payment, upper thresholds), condition, and year and cluster on indicators. We find that the proportion of patients with a given condition for whom a quality indicator was achieved was higher, and the proportion who were exception reported was lower, for multi-reward indicators than for single reward indicators. We also exploit the replacement of multi-reward smoking indicators by single reward indicators in 2006/7. Compared to indicators which were always single or always multi-reward, the proportion of the relevant patients for whom the smoking indicators were achieved fell when the smoking indicators were no longer multi-reward. Fine details of pay for performance schemes matter: they affect physician behaviour and patient outcomes.
Community orientation of general practitioners in 34 countries
2018, Health Policy
General practitioners (GPs) are frontline health workers. They should be sensitive to the health needs of the community in addition to caring for patients that visit their practice. Due to changes in demography, epidemiology, ecology and healthcare policy, a community orientation becomes more important. Our research question is: to what extent does community orientation of GPs vary between countries and GPs and how can this variation be explained? We use cross-sectional survey data from the QUALICOPC study, conducted among over 7000 GPs in 34 countries. Community orientation was measured through a scale constructed from three survey questions on whether GPs would take action when confronted with: repeated accidents in an industrial setting, frequent respiratory problems in patients living near a certain industry, and repeated cases of food poisoning in the local community. Independent variables are at healthcare system level and GP or practice level. Data were analysed using linear multilevel regression analysis. Community orientation varies between GPs and countries. Community orientation is more frequent in healthcare systems with a list system, among self-employed GPs, those using medical records to make overviews, and those more active in prevention and multidisciplinary cooperation. GPs in rural areas and areas with more people from ethnic minorities are more community oriented. Based on the variation between countries and GPs, we would like to raise awareness and underline the importance of multidisciplinary cooperation.
Equilibrium informativeness in veto games
2018, Games and Economic Behavior
In a veto game a biased expert recommends an action that an uninformed decision maker can accept or reject for an outside option. The arrangement is ubiquitous in political institutions, corporations, and consumer markets but has seen limited use in applications due to a poor understanding of the equilibrium set and an ensuing debate over selection. We develop a simple method to construct every veto equilibrium and identify the most informative equilibrium in a setting that spans prior work. We show that Krishna and Morgan's (2001) equilibrium is maximally informative and strengthen Dessein's (2002) comparison of full delegation and veto. In an application we study the relationship between a patient and a doctor with a financial incentive to overtreat, and show that the doctor's bias harms the patient both through excessive treatment and information loss, that the latter can be substantial, and that insurance benefits both parties by improving communication.
Does enrollment in multidisciplinary team-based primary care practice improve adherence to guideline-recommended processes of care? Quebec's Family Medicine Groups, 2002–2010
2017, Health Policy
We investigated whether multidisciplinary team-based primary care practice improves adherence to process of care guidelines, in the absence of financial incentives related to pay-for-performance.
We conducted a natural experiment including 135,119 patients, enrolled with a general practitioner (GP) in a multidisciplinary team Family Medicine Group (FMG) or non-FMG practice, using longitudinal data from Quebec's universal insurer over the relevant time period (2000–2010). All study subjects had diabetes, chronic obstructive pulmonary disease, or heart failure and were followed over a 7-year period, 2 years prior to enrollment and 5 years after. We constructed indicators on adherence to disease-specific guidelines and composite indicators across conditions. We evaluated the effect of FMGs using propensity score methods and Difference-in-Differences (DD) models.
Rates of adherence to chronic disease guidelines increased for both FMG and non-FMG patients after enrollment, but not differentially so. Adherence to prescription-related guidelines improved less for FMG patients (DD [95% CI] = −2.83% [−4.08%, −1.58%]). We found no evidence of an FMG effect on adherence to consultation-related guidelines, (DD [95% CI] = −0.24% [−2.24%; 1.75%]).
We found no evidence that FMGs increased adherence to the guidelines we evaluated. Future research is needed to assess why this reform did not improve performance on these quality-of-care indicators.
The influence of welfare systems on pay-for-performance programs for general practitioners: A critical review
2017, Social Science and Medicine
While pay-for-performance (P4P) programs are increasingly common tools used to foster quality and efficiency in primary care, the evidence concerning their effectiveness is at best mixed. In this article, we explore the influence of welfare systems on four P4P-related dimensions: the level of healthcare funders' commitment to P4Ps (by funding and length of program operation), program design (specifically target-based vs. participation-based program), physicians' acceptance of the program and program effects. Using Esping-Andersen's typology, we examine P4P for general practitioners (GPs) in thirteen European and North American countries and find that welfare systems contribute to explain variations in P4P experiences. Overall, liberal systems exhibited the most enthusiastic adoption of P4P, with significant physician acceptance, generous incentives and positive but modest program effects. Social democratic countries showed minimal interest in P4P for GPs, with the exception of Sweden. Although corporatist systems adopted performance pay, these countries experienced mixed results, with strong physician opposition. In response to this opposition, health care funders tended to favour participation-based over target-based P4P. We demonstrate how the interaction of decommodification and social stratification in each welfare regime influences these countries' experiences with P4P for GPs, directly for funders' commitment, program design and physicians' acceptance, and indirectly for program effects, hence providing a framework for analyzing P4P in other contexts or care settings.

View all citing articles on Scopus

: The full text of this article is available via AJPM online at www.ajpm-online.net.

View full text

Review and special articlesEconomic incentives and physicians’ delivery of preventive care: A systematic review

Abstract

Introduction

Section snippets

Definition of prevention

Results

Discussion

Am J Prev Med

Am J Prev Med

Ambul Pediatr

Am J Prev Med

Prev Med

Am J Prev Med

J Health Econ

Healthy People 2010

Five hundred life-saving interventions and their cost-effectiveness

Risk Analysis

Review and special articles
Economic incentives and physicians’ delivery of preventive care: A systematic review