Financial incentives linked to quality improvement projects in Swedish primary care: a model for improving quality of care

Background

Quality improvement (QI) is necessary in all healthcare, but quality of healthcare is hard to measure. To use financial incentives to improve care is difficult and may even be harmful. However, conducting QI projects is a well-established way to increase quality in healthcare.

Problem

In 2015, there were few QI projects conducted in primary care in the Stockholm Region, Sweden. There was no structured support or way to share the QI projects with other general practitioner (GP) practices. To use financial incentives could increase the number of projects performed and could possibly improve the quality of care. The aim was to increase the number of GP practices performing QI projects in the Stockholm Region through financial incentives.

Method

To study QI projects performed during 2016 and 2017 in the Region Stockholm. This was compared with 2015 in Stockholm and with the Region Jönköping in Sweden during 2016 and 2017.

Interventions

First, the healthcare administration started to reimburse GP practices for conducting and reporting QI projects in 2016. Second, a 4-hour course in QI was offered. Third, feedback on plans for QI projects was given. The year after the projects were prerformed, they were published online to stimulate sharing and inspiration between the GP practices.

Results

For 2016, there were 166 (80%) of the GP practices that presented a QI project and in 2017, 164 (79%) did so. The number of projects in Stockholm increased almost by 100 per years compared with 2015.

Conclusion

QI work has increased in Stockholm since 2016, probably because of the financial incentives from the Stockholm Region.

Relationship between physician financial incentives and clinical pathway compliance: a cross-sectional study of 18 public hospitals in China

OBJECTIVES

Many strategies have been either used or recommended to promote physician compliance with clinical practice guidelines and clinical pathways (CPs). This study examines the relationship between hospitals' use of financial incentives to encourage physician compliance with CPs and physician adherence to CPs.

DESIGN

A retrospectively cross-sectional study of the relationship between the extent to which patient care was consistent with CPs and hospital's use of financial incentives to influence CP compliance.

SETTING

Eighteen public hospitals in three provinces in China.

PARTICIPANTS

Stratified sample of 2521 patients discharged between 3 January 2013 and 31 December 2014.

PRIMARY OUTCOME MEASURES

The proportion of key performance indicators (KPIs) met for patients with (1) community-acquired pneumonia (pneumonia), (2) acute myocardial infarction (AMI), (3) acute left ventricular failure (heart failure), (4) planned caesarean section (C-section) and (5) gallstones associated with acute cholecystitis and associated cholecystectomy (cholecystectomy).

RESULTS

The average implementation rate of CPs for five conditions (pneumonia, AMI, heart failure, C-section and cholecystectomy) based on 2521 cases in 18 surveyed hospitals was 57% (ranging from 44% to 67%), and the overall average compliance rate for the KPIs for the five conditions was 69.48% (ranging from 65.07% to 77.36%). Implementation of CPs was associated with greater compliance within hospitals only when hospitals adopted financial incentives directed at physicians to promote compliance.

CONCLUSION

CPs are viewed as important strategies to improve medical care in China, but they have not been widely implemented or adhered to in Chinese public hospitals. In addition to supportive resources, education/training and better administration in general, hospitals should provide financial incentives to encourage physicians to adhere to CPs.

Parental Perspectives on Financial Incentives for Adolescents: Findings From Qualitative Interviews

Background. Financial incentives are becoming more common to promote health behaviors; however, little is known about the acceptability of incentivizing adolescent health behaviors. Design. Qualitative semistructured phone interviews were conducted with 26 parents who had participated in a research study involving incentivizing a recommended, preventive adolescent health behavior (human papillomavirus vaccination). Data were coded and analyzed to identify themes. Interview domains included the following: preferred incentive distribution, ideal financial incentive amount, and general reactions to economic incentives for preventative services. Results. Parents held positive perceptions about incentives and most parents felt that the incentive could be provided directly to their adolescent child, rather than to the parent. Parents stated several benefits from incentivizing adolescent health behavior including creating an opportunity to teach their child about money, reimbursing families for time and effort, and motivating the adolescent to complete the health behavior. Topics for consideration when providing cash incentives to adolescents included the adolescent's maturity level, parents' desire to monitor adolescent's spending, and parents' want to remain involved in health care and financial decisions for their adolescent. Conclusions. This study demonstrates the potential for parental acceptance of financial incentives for adolescent health behaviors and explores areas of parental concern around financial incentives, which could help inform future health care-based incentive programs.

Did we learn the lesson after 60 years of Management by Objectives? A survey among former physician executives in German hospitals

BACKGROUND

Management by Objectives (MbO) has been shown to establish efficient team work in both industry and medicine. Its most important prerequisite for success is target agreements between managers and medical professionals on equal footing. In medicine, lump-sum financing urges the delivery of a health care service with minimal effort. Consequently, daily clinical life changed, with economic goals seeming to become priority over medical principles.

OBJECTIVE

To determine how well MbO can still be practiced in hospitals with lumped treatment prices.

METHODS

We used an anonymized questionnaire for already retired physician executives who completed their active leadership positions between 2010 and 2015 in Saxony (Germany). We asked various type of target agreements that had been used in order to achieve medical or economic targets.

RESULTS AND CONCLUSIONS

Out of 111 former executives, the questionnaires of 25 respondents could be analysed. Eight respondents confirmed target agreements that were mostly set by managing directors. If used, most targets had not been adapted to the infrastructure and personnel strength, nor were they coordinated with neighbouring departments. Four respondents received financial incentives. Most medical executives were unsatisfied and preferred to abandon further goal setting. Due to the low number of cases, the representativeness of the study is limited. Nevertheless, it might be questioned if a flat-rate remuneration system facilitates the change into an authoritarian leadership concept.

Race Differences in Physical Activity Uptake Within a Workplace Wellness Program: A Comparison of Black and White Employees

PURPOSE

To examine differences in physical activity (PA) uptake between black and white employees during a financial incentive-based workplace intervention.

DESIGN

Prospective cohort study from July 2014 to June 2015 (NCT02850094).

SETTING

Tertiary academic medical center.

PARTICIPANTS

Forty-three black and 182 white nonclinical employees.

INTERVENTION

Participants self-selected or were assigned to teams. Participants completed a 24-week intervention receiving rewards for meeting weekly PA goals (increasing moderate-to-vigorous PA [MVPA] by 10% from previous week or meeting Guidelines threshold of 150 minutes of MVPA).

MEASURES

Outcomes included weekly MVPA in minutes, average daily step counts, number of weeks meeting personal goals and the Guidelines, and Fitbit adherence in days and weeks.

ANALYSIS

We performed an analysis of covariance for each outcome, with race as the primary independent variable of interest, adjusting for demographic and health-related covariates.

RESULTS

During the intervention, blacks walked 9128 steps per day while whites walked 7826 steps per day, a difference of approximately 1300 steps (P < .05). Blacks also demonstrated a greater uptake in both steps and MVPA from baseline than did whites, resulting in similar MVPA throughout the intervention.

CONCLUSIONS

Findings suggest that workplace PA interventions using financial incentives may result in similar engagement in MVPA among white and black employees, while black employees walk more steps during the intervention. Limitations include a primarily white female sample which may not generalize.

Understanding Participants' Perceptions of Access to and Satisfaction With Chronic Disease Prevention Programs

Despite the promise of incentive-based chronic disease prevention programs, comprehensive evidence on their accessibility among low-income populations remains limited. We adapted Aday and Andersen's framework to examine accessibility and consumer satisfaction within the Medicaid Incentives for the Prevention of Chronic Disease (MIPCD) cross-site demonstration. MIPCD provided 10 states with 5-year grants to implement incentivized chronic disease prevention and management programs for low-income and/or disabled-Medicaid enrolled-Americans. We conducted 36 focus group discussions between July 2014 and December 2015 with Medicaid enrollees participating in the MIPCD programs. We assessed participants' satisfaction by program type (i.e., diabetes prevention, diabetes management, hypertension reduction, smoking cessation, and weight management) related to three components: program enrollment and participation, staff courtesy, and program convenience. Based on Aday and Andersen's framework, we conducted thematic analysis to determine similarities and differences across MIPCD programs by type. Participant feedback confirmed the importance of several features of the Aday and Andersen framework, particularly programs with easy enrollment and participation procedures, courteous and helpful staff, and those that are convenient and flexible for participants. Participants valued programming around the clock via telephone and flexible, in-person hours of operation as well as proximity of the program to reliable transportation. We observed that most participants, despite enrollment and participation barriers, perceived programs as accessible and were willing to engage and continue to participate. This finding may reflect behavior change theory's perspective on personal readiness to change. Individuals in the preparation stage of change can effectively change health habits despite barriers they may encounter. In some cases, personal readiness to change was more impactful than consumer satisfaction at encouraging ongoing participation and perceived access to the programs. Thus, program developers may want to consider individual participant readiness to change and its impact on consumer satisfaction when designing, implementing, and evaluating behavior change initiatives.

A New Approach for Lifestyle Medicine Payment

With more than 85% of health care costs attributable to chronic health conditions, an emphasis on treating the underlying causes of these conditions is imperative. Lifestyle medicine offers treatments that can reverse a wide range of chronic health conditions at minimal cost and without negative side effects. Although one might expect its use to be widespread among health care professionals, it is far from common in everyday practice. A significant contributing factor is the lack of financial incentives for health care providers who practice lifestyle medicine. Current practitioners generally do not receive remuneration consistent with the cost savings resulting from reversing chronic health conditions using lifestyle medicine. The Actuarial Patient Value model offers a new approach to encourage the practice of lifestyle medicine through the use of cash financial incentives based on actual patient health outcomes. This model aligns the incentives of the 3 primary stakeholders in the health care system by offering providers increased compensation, giving patients the opportunity to learn about and achieve optimal health, and reducing costs for health care payers.

Influence of financial and reputational incentives on primary care performance: a longitudinal study

BACKGROUND

The Quality and Outcomes Framework has generated reputational as well as financial rewards for general practices because the number of quality points a practice receives is publicly reported. These rewards vary across diseases and practices, and over time.

AIM

To determine the relative effects on performance of the financial and reputational rewards resulting from a pay-for-performance programme.

DESIGN AND SETTING

Observational study of the published performance on 42 indicators of 8929 practices in England between 2004 and 2013.

METHOD

The authors calculated the revenue offered (financial reward, measured in £100s) and the points offered (reputational reward) per additional patient treated for each indicator for each practice in each year. Fixed-effects multivariable regression models were used to estimate whether the percentage of eligible patients treated responded to changes in these financial and reputational rewards.

RESULTS

Both the offered financial rewards and reputational rewards had small but statistically significant associations with practice performance. The effect of the financial reward on performance decreased from 0.797 percentage points per £100 (95% confidence interval [CI] = 0.614 to 0.979) in 2004, to 0.092 (95% CI = 0.045 to 0.138) in 2013. The effect of the reputational reward increased from -0.121 percentage points per quality point (95% CI = -0.220 to -0.022) in 2004, to 0.209 (95% CI = 0.147 to 0.271) in 2013.

CONCLUSION

In the short term, general practices were more sensitive to revenue than reputational rewards. In the long term, general practices appeared to divert their focus towards the reputational reward, once benchmarks of performance became established.

'Secretly, it's a competition': a qualitative study investigating what helped employees quit smoking during a workplace smoking cessation group training programme with incentives

OBJECTIVES

Smoking cessation programmes in combination with financial incentives have shown to increase quit rates in smokers, but it is not clear which elements of this intervention help smokers to succeed in their quit attempt. The aim of this study was to explore the view of successful and unsuccessful quitters about which factors had affected their ability to quit smoking.

DESIGN

Semistructured qualitative interviews were conducted and analysed using the Framework method.

SETTING

Interviews were conducted in 2017 with employees from nine different Dutch companies.

PARTICIPANTS

24 successful and unsuccessful quitters from the intervention group of a cluster randomised controlled trial (RCT) who participated in a workplace smoking cessation group training programme in which smoking abstinence was rewarded with financial incentives.

RESULTS

Themes that emerged were the workplace setting, quitting with colleagues, motivation, family support, strategies and the financial incentives. The interviewees reported that the smoking cessation programme was appreciated in general, was convenient, lowered the threshold to sign up, stimulated peer support and competition and provided strategies to resist smoking. Personal motivation and a mind set to never smoke again were regarded as important factors for quit success. The financial incentives were not considered as a main motivator to quit smoking, which contradicts the results from the RCT. The financial incentives were considered as more attractive to smokers with a low income.

CONCLUSIONS

According to participants, contributors to quitting smoking were the workplace cessation programme, personal motivation and peer support, but not the incentives. More research is needed on the contradiction between the perceived effects of financial incentives on quit success and the actual difference in quit rates.

TRIAL REGISTRATION NUMBER

NTR5657.

Provider Incentives and Healthcare Costs: Evidence from Long-Term Care Hospitals

We study the design of provider incentives in the post-acute care setting - a high-stakes but under-studied segment of the healthcare system. We focus on long-term care hospitals (LTCHs) and the large (approximately $13,500) jump in Medicare payments they receive when a patient s stay reaches a threshold number of days. Discharges increase substantially after the threshold, with the marginal discharged patient in relatively better health. Despite the large financial incentives and behavioral response in a high mortality population, we are unable to detect any compelling evidence of an impact on patient mortality. To assess provider behavior under counterfactual payment schedules, we estimate a simple dynamic discrete choice model of LTCH discharge decisions. When we conservatively limit ourselves to alternative contracts that hold the LTCH harmless, we find that an alternative contract can generate Medicare savings of about $2,100 per admission, or about 5% of total payments. More aggressive payment reforms can generate substantially greater savings, but the accompanying reduction in LTCH profits has potential out-of-sample consequences. Our results highlight how improved financial incentives may be able to reduce healthcare spending, without negative consequences for industry profits or patient health.

Evaluation of a Computer-Based Training Program to Teach Adults at Risk for HIV About Pre-Exposure Prophylaxis

This study developed a computer-based program to teach HIV prevention behaviors and raise awareness of pre-exposure prophylaxis (PrEP) among individuals at risk for HIV. The program was divided into modules containing educational material and multiple-choice questions. Participants received immediate feedback for responses and incentives for correct responses to multiple-choice questions. Participants trained on each module until they met speed and accuracy criteria. The modules were divided into: Course 1 (HIV), Course 2 (PrEP), and Course 3 (HIV risk behaviors). Tests of content from all three courses were delivered before and after participants completed each course. Test scores on the content delivered in the courses improved only after participants completed training on each course. HIV and PrEP knowledge was initially low and increased following completion of each part of the program. Computer-based training offers a convenient and effective approach to promoting HIV prevention knowledge, including use of PrEP.

Effect of Process- and Outcome-Based Financial Incentives on Weight Loss Among Prediabetic New York Medicaid Patients: A Randomized Clinical Trial

PURPOSE

To determine whether different financial incentives are effective in promoting weight loss among prediabetic Medicaid recipients.

DESIGN

Four-group, multicenter, randomized clinical trial.

SETTING AND PARTICIPANTS

Medicaid managed care enrollees residing in New York, aged 18 to 64 years, and diagnosed as prediabetic or high risk for diabetes (N = 703).

INTERVENTION

In a 16-week program, participants were randomly assigned to one of 4 arms: (1) control (no incentives), (2) process incentives for attending weekly Diabetes Prevention Program sessions, (3) outcome incentives for achieving weekly weight loss goals, and (4) combined process and outcome incentives.

MEASURES

Weight loss over a 16-week period; proportion who completed educational sessions; proportion who met weight loss goals.

ANALYSIS AND RESULTS

No intervention arm achieved greater reduction in weight than control (outcome incentive -6.6 lb [-9.1 to -4.1 lb], process incentive -7.3 lb [-9.5 to -5.1 lb], combined incentive -5.8 lb [-8.8 to -2.8 lb], control -7.9 lb [-11.1 to -4.7 lb]; all P > .29). Session attendance in the process incentive arm (50%) was significantly higher than control (31%; P < .0001) and combined incentive arms (28%; P < .0001), but not significantly higher than the outcome incentive arm (38%).

CONCLUSION

Process incentives increased session attendance, but when combined at half strength with outcome incentives did not achieve that effect. There were no significant effects of either process or outcomes incentives on weight loss.

Impact of Agency Receipt of Incentives and Reminders on Engagement and Continuity of Care for Clients With Co-Occurring Disorders

OBJECTIVE

This study examined whether having co-occurring substance use and mental disorders influenced treatment engagement or continuity of care and whether offering financial incentives, client-specific electronic reminders, or a combination to treatment agencies improved treatment engagement and continuity of care among clients with co-occurring disorders.

METHODS

The study used a randomized cluster design to assign agencies (N=196) providing publicly funded substance use disorder treatment in Washington State to a research arm: incentives only, reminders only, incentives and reminders, and a control condition. Data were analyzed for 76,044 outpatient, 32,797 residential, and 39,006 detoxification admissions from Washington's treatment data system. Multilevel logistic regressions were conducted, with clients nested within agencies, to examine the effect of the interventions on treatment engagement and continuity of care.

RESULTS

Compared with clients with a substance use disorder only, clients with co-occurring disorders were less likely to engage in outpatient treatment or have continuity of care after discharge from residential treatment, but they were more likely to have continuity of care after discharge from detoxification. The interventions did not influence treatment engagement or continuity of care, except the reminders had a positive impact on continuity of care after residential treatment among clients with co-occurring disorders.

CONCLUSIONS

In general, the interventions did not result in improved treatment engagement or continuity of care. The limited number of significant results supporting the influence of incentives and alerts on treatment engagement and continuity of care add to the mixed findings reported by previous research. Multiple interventions may be needed for performance improvement.

Pay-for-Performance and Veteran Care in the VHA and the Community: a Systematic Review

BACKGROUND

Although pay-for-performance (P4P) strategies have been used by the Veterans Health Administration (VHA) for over a decade, the long-term benefits of P4P are unclear. The use of P4P is further complicated by the increased use of non-VHA healthcare providers as part of the Veterans Choice Program. We conducted a systematic review and key informant interviews to better understand the effectiveness and potential unintended consequences of P4P, as well as the implementation factors and design features important in both VHA and non-VHA/community settings.

METHODS

We searched PubMed, PsycINFO, and CINAHL through March 2017 and reviewed reference lists. We included trials and observational studies of P4P targeting Veteran health. Two investigators abstracted data and assessed study quality. We interviewed VHA stakeholders to gain further insight.

RESULTS

The literature search yielded 1031 titles and abstracts, of which 30 studies met pre-specified inclusion criteria. Twenty-five examined P4P in VHA settings and 5 in community settings. There was no strong evidence supporting the effectiveness of P4P in VHA settings. Interviews with 17 key informants were consistent with studies that identified the potential for overtreatment associated with performance metrics in the VHA. Key informants' views on P4P in community settings included the need to develop relationships with providers and health systems with records of strong performance, to improve coordination by targeting documentation and data sharing processes, and to troubleshoot the limited impact of P4P among practices where Veterans make up a small fraction of the patient population.

DISCUSSION

The evidence to support the effectiveness of P4P on Veteran health is limited. Key informants recognize the potential for unintended consequences, such as overtreatment in VHA settings, and suggest that implementation of P4P in the community focus on relationship building and target areas such as documentation and coordination of care.

Loss-Framed Financial Incentives and Personalized Goal-Setting to Increase Physical Activity Among Ischemic Heart Disease Patients Using Wearable Devices: The ACTIVE REWARD Randomized Trial

Background

Regular physical activity reduces the risk of cardiovascular events, but most ischemic heart disease (IHD) patients do not obtain enough.

Methods and Results

ACTIVE REWARD (A Clinical Trial Investigating Effects of a Randomized Evaluation of Wearable Activity Trackers with Financial Rewards) was a 24‐week home‐based, remotely monitored, randomized trial with a 16‐week intervention (8‐week ramp‐up incentive phase and 8‐week maintenance incentive phase) and an 8‐week follow‐up. Patients used wearable devices to track step counts and establish a baseline. Patients in control received no other interventions. Patients in the incentive arm received personalized step goals and daily feedback for all 24 weeks. In the ramp‐up incentive phase, daily step goals increased weekly by 15% from baseline with a maximum of 10 000 steps and then remained fixed. Each week, $14 was allocated to a virtual account; $2 could be lost per day for not achieving step goals. The primary outcome was change in mean daily steps from baseline to the maintenance incentive phase. Ischemic heart disease patients had a mean (SD) age of 60 (11) years and 70% were male. Compared with control, patients in the incentive arm had a significantly greater increase in mean daily steps from baseline during ramp‐up (1388 versus 385; adjusted difference, 1061 [95% confidence interval, 386–1736]; P<0.01), maintenance (1501 versus 264; adjusted difference, 1368 [95% confidence interval, 571–2164]; P<0.001), and follow‐up (1066 versus 92; adjusted difference, 1154 [95% confidence interval, 282–2027]; P<0.01).

Conclusions

Loss‐framed financial incentives with personalized goal setting significantly increased physical activity among ischemic heart disease patients using wearable devices during the 16‐week intervention, and effects were sustained during the 8‐week follow‐up.

Clinical Trial Registration

URL: https://www.clinicaltrials.gov. Unique identifier: NCT02531022.

Are Financial Incentives for Lifestyle Behavior Change Informed or Inspired by Behavioral Economics? A Mapping Review

OBJECTIVE

To identify the behavioral economics (BE) conceptual underpinnings of lifestyle financial incentive (FI) interventions.

DATA SOURCE

A mapping review of peer-reviewed literature was conducted by searching electronic databases.

STUDY INCLUSION AND EXCLUSION CRITERIA

Inclusion criteria were real-world FI interventions explicitly mentioning BE, targeting individuals, or populations with lifestyle-related behavioral outcomes. Exclusion criteria were hypothetical studies, health professional focus, clinically oriented interventions.

DATA EXTRACTION

Study characteristics were tabulated according to purpose, categorization of BE concepts and FI types, design, outcome measures, study quality, and findings.

DATA SYNTHESIS AND ANALYSIS

Financial incentives were categorized according to type and payment structure. Behavioral economics concepts explicitly used in the intervention design were grouped based on common patterns of thinking. The interplay between FI types, BE concepts, and outcome was assessed.

RESULTS

Seventeen studies were identified from 1452 unique records. Analysis showed 76.5% (n = 13) of studies explicitly incorporated BE concepts. Six studies provided clear theoretical justification for the inclusion of BE. No pattern in the type of FI and BE concepts used was apparent.

CONCLUSIONS

Not all FI interventions claiming BE inclusion did so. For interventions that explicitly included BE, the degree to which this was portrayed and woven into the design varied. This review identified BE concepts common to FI interventions, a first step in providing emergent and pragmatic information to public health and health promotion program planners.

A Randomized, Controlled Trial of Lottery-Based Financial Incentives to Increase Physical Activity Among Overweight and Obese Adults

PURPOSE

To evaluate the effect of lottery-based financial incentives in increasing physical activity.

DESIGN

Randomized, controlled trial.

SETTING

University of Pennsylvania Employees.

PARTICIPANTS

A total of 209 adults with body mass index ≥27.

INTERVENTIONS

All participants used smartphones to track activity, were given a goal of 7000 steps per day, and received daily feedback on performance for 26 weeks. Participants randomly assigned to 1 of the 3 intervention arms received a financial incentive for 13 weeks and then were followed for 13 weeks without incentives. Daily lottery incentives were designed as a "higher frequency, smaller reward" (1 in 4 chance of winning $5), "jackpot" (1 in 400 chance of winning $500), or "combined lottery" (18% chance of $5 and 1% chance of $50).

MEASURES

Mean proportion of participant days step goals were achieved.

ANALYSIS

Multivariate regression.

RESULTS

During the intervention, the unadjusted mean proportion of participant days that goal was achieved was 0.26 in the control arm, 0.32 in the higher frequency, smaller reward lottery arm, 0.29 in the jackpot arm, and 0.38 in the combined lottery arm. In adjusted models, only the combined lottery arm was significantly greater than control ( P = .01). The jackpot arm had a significant decline of 0.13 ( P < .001) compared to control. There were no significant differences during follow-up.

CONCLUSIONS

Combined lottery incentives were most effective in increasing physical activity.

Pay-for-performance incentive program in a large dental group practice

BACKGROUND

Dentists increasingly are employed in large group practices that use financial incentive systems to influence provider performance. The authors describe the design and initial implementation of a pay-for-performance (P4P) incentive program for a large capitated Oregon group dental practice that cares primarily for patients receiving Medicaid. The authors do not assess the effectiveness of the incentive system on provider and staff member performance.

METHODS

The data come from use of care files and integrated electronic health records, provider and staff member surveys, and interviews and community surveys from 6 counties. Quarterly individual- and team-level incentives focused on 3 performance metrics.

RESULTS

The program was challenged by many complex administrative issues. The key issues included designing a P4P system for different types of providers and administrative staff members who were employed centrally and in different communities, setting realistic performance metrics, building information systems that provided timely information about performance, and educating and gaining the support of a diverse workforce. Adjustments are being made in the incentive scheme to meet these challenges.

CONCLUSIONS

This is the first report of a P4P compensation system for dental care providers and supporting staff members. The complex administrative challenges will require several years to address.

PRACTICAL IMPLICATIONS

Large, capitated dental practice organizations will employ more dental care providers and administrative staff members to care for patients who receive Medicaid and patients who are privately insured. It is critical to design and implement a P4P system that the workforce supports.

A randomized trial of contingency management for smoking cessation in the homeless

Smoking-cessation services are an unmet need among the homeless, who smoke at rates more than 4 times the national estimate. Successful interventions have high potential for improving tobacco-related health disparities among homeless smokers. Contingency management (CM) is a behavioral intervention with efficacy in a number of substance-use disorder populations, including smokers. However, no randomized studies have evaluated the effect of CM in homeless smokers. We examined smoking-related outcomes in homeless smokers (N = 70) randomized to standard-care (SC) smoking cessation involving transdermal nicotine-replacement therapy (NRT), standard counseling, and carbon monoxide (CO) monitoring or the same SC plus CM for negative CO sample submissions. Participants randomized to CM achieved significantly longer durations of consecutive abstinence and submitted a significantly higher proportion of CO-negative samples relative to standard-care participants. At 4 weeks postquit day, 22% were abstinent in the CM condition and 9% were abstinent in the SC condition. At the 6-month follow-up, about 10% of smokers in both conditions were abstinent. This study demonstrates that CM is an efficacious option to increase initial quit rates in homeless smokers, but methods to extend effects are needed. (PsycINFO Database Record

Financial Incentives Differentially Regulate Neural Processing of Positive and Negative Emotions during Value-Based Decision-Making

Emotional and economic incentives often conflict in decision environments. To make economically desirable decisions then, deliberative neural processes must be engaged to regulate automatic emotional reactions. In this functional magnetic resonance imaging (fMRI) study, we evaluated how fixed wage (FW) incentives and performance-based (PB) financial incentives, in which pay is proportional to outcome, differentially regulate positive and negative emotional reactions to hypothetical colleagues that conflicted with the economics of available alternatives. Neural activity from FW to PB incentive contexts decreased for positive emotional stimuli but increased for negative stimuli in middle temporal, insula, and medial prefrontal regions. In addition, PB incentives further induced greater responses to negative than positive emotional decisions in the frontal and anterior cingulate regions involved in emotion regulation. Greater response to positive than negative emotional features in these regions also correlated with lower frequencies of economically desirable choices. Our findings suggest that whereas positive emotion regulation involves a reduction of responses in valence representation regions, negative emotion regulation additionally engages brain regions for deliberative processing and signaling of incongruous events.

Acceptability and satisfaction of project MOVE: A pragmatic feasibility trial aimed at increasing physical activity in female breast cancer survivors

Objective

Despite the physical and psychological health benefits associated with physical activity (PA) for breast cancer (BC) survivors, up to 70% of female BC survivors are not meeting minimum recommended PA guidelines. The objective of this study was to evaluate acceptability and satisfaction with Project MOVE, an innovative approach to increase PA among BC survivors through the combination of microgrants and financial incentives.

Methods

A mixed‐methods design was used. Participants were BC survivors and support individuals with a mean age of 58.5 years. At 6‐month follow‐up, participants completed a program evaluation questionnaire (n = 72) and participated in focus groups (n = 52) to explore their experience with Project MOVE.

Results

Participants reported that they were satisfied with Project MOVE (86.6%) and that the program was appropriate for BC survivors (96.3%). Four main themes emerged from focus groups: (1) acceptability and satisfaction of Project MOVE, detailing the value of the model in developing tailored group‐base PA programs; (2) the importance of Project MOVE leaders, highlighting the value of a leader that was organized and a good communicator; (3) breaking down barriers with Project MOVE, describing how the program helped to address common BC related barriers; and (4) motivation to MOVE, outlining how the microgrants enabled survivors to be active, while the financial incentive motivated them to increase and maintain their PA.

Conclusion

The findings provide support for the acceptability of Project MOVE as a strategy for increasing PA among BC survivors.

Administrative reform and pay-for-performance methods of primary health service delivery: A comparison of 3 health districts in Cambodia, 2006-2012

Since 1999, performance-based financing or pay-for-performance (P4P) methods have been piloted in the Cambodian public health sector, first as one part of external contracting approaches with international nongovernment organizations and from 2009 as a part of internal contracting arrangements between units within the Ministry of Health under a wider public sector administrative reform. This study analyses these reforms and compares outcomes in 3 health districts. The study analysed routine quantitative data for primary care service delivery by using the interrupted time series method. Qualitative data were collected from key informant interviews. Both the level and the trend line of key service delivery indicators during earlier contracting/P4P models were at least maintained and in most cases increased with the move to internal contracting. The results of the interrupted time series analysis were mixed, mainly due to contextual issues. Qualitative results indicated an increased sense of local ownership and financial sustainability. Despite the gains, the management of personnel and the implementation and the integrity of contract monitoring were found to be compromised in this case. To be fully effective, contracting and P4P approaches must be accompanied by changes in the structure and culture of government administration.