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