Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues

A health insurance company-initiated practice support intervention for optimizing acid-suppressing drug prescriptions in primary care

BACKGROUND

A health insurance-initiated programme to improve cost-effectiveness of acid-suppressing drugs (ASDs).

AIM

To evaluate the effect of two different interventions of general practitioner support in reducing drug prescription.

MATERIALS AND METHODS

A sequential cluster randomized controlled trial with 90 participating general practitioners in a telephone support (TS) group or practice visit (PV) group. TS group received support in phase-1 (first 6 months), but served as control group in phase-2 (6-12 months period). PV group received no intervention in phase-1, serving as the control group for the TS group, but received support in phase-2. Prescription data were extracted from Agis Health Insurance Database. Outcomes were the proportion of responders to drug reduction and the number of defined daily dose (DDD). Differences in users and DDD were analysed using multilevel regression analysis.

RESULTS

At baseline, 3424 patients used ASD chronically (211 DDDs, on average). The difference between TS and control groups among responders was 3.2% [95% confidence interval (CI): 0.8; 5.6] and relative risk was 1.26 (95% CI: 1.06; 1.51). The difference between PV and control groups was not relevant (0.4%, 95% CI: -1.99; 2.79 and relative risk: 1.01, 95% CI: 0.82; 1.20). The difference in DDD per patient was -3.0 (95% CI: -8.9; 2.9) and -5.82 (95% CI: -12.4; 0.73), respectively.

CONCLUSION

This health insurance company-initiated intervention had a moderate effect on ASD prescription. In contrast to TS, PVs did not seem to reduce ASD prescription rates.

An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes

BACKGROUND

There is considerable interest in the effectiveness of financial incentives in the delivery of health care. Incentives may be used in an attempt to increase the use of evidence-based treatments among healthcare professionals or to stimulate health professionals to change their clinical behaviour with respect to preventive, diagnostic and treatment decisions, or both. Financial incentives are an extrinsic source of motivation and exist when an individual can expect a monetary transfer which is made conditional on acting in a particular way. Since there are numerous reviews performed within the healthcare area describing the effects of various types of financial incentives, it is important to summarise the effectiveness of these in an overview to discern which are most effective in changing health professionals' behaviour and patient outcomes.

OBJECTIVES

To conduct an overview of systematic reviews that evaluates the impact of financial incentives on healthcare professional behaviour and patient outcomes.

METHODS

We searched the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library); Database of Abstracts of Reviews of Effectiveness (DARE); TRIP; MEDLINE; EMBASE; Science Citation Index; Social Science Citation Index; NHS EED; HEED; EconLit; and Program in Policy Decision-Making (PPd) (from their inception dates up to January 2010). We searched the reference lists of all included reviews and carried out a citation search of those papers which cited studies included in the review. We included both Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs), controlled clinical trials (CCTs), interrupted time series (ITSs) and controlled before and after studies (CBAs) that evaluated the effects of financial incentives on professional practice and patient outcomes, and that reported numerical results of the included individual studies. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR criteria. We included systematic reviews of studies evaluating the effectiveness of any type of financial incentive. We grouped financial incentives into five groups: payment for working for a specified time period; payment for each service, episode or visit; payment for providing care for a patient or specific population; payment for providing a pre-specified level or providing a change in activity or quality of care; and mixed or other systems. We summarised data using vote counting.

MAIN RESULTS

We identified four reviews reporting on 32 studies. Two reviews scored 7 on the AMSTAR criteria (moderate, score 5 to 7, quality) and two scored 9 (high, score 8 to 11, quality). The reported quality of the included studies was, by a variety of methods, low to moderate. Payment for working for a specified time period was generally ineffective, improving 3/11 outcomes from one study reported in one review. Payment for each service, episode or visit was generally effective, improving 7/10 outcomes from five studies reported in three reviews; payment for providing care for a patient or specific population was generally effective, improving 48/69 outcomes from 13 studies reported in two reviews; payment for providing a pre-specified level or providing a change in activity or quality of care was generally effective, improving 17/20 reported outcomes from 10 studies reported in two reviews; and mixed and other systems were of mixed effectiveness, improving 20/31 reported outcomes from seven studies reported in three reviews. When looking at the effect of financial incentives overall across categories of outcomes, they were of mixed effectiveness on consultation or visit rates (improving 10/17 outcomes from three studies in two reviews); generally effective in improving processes of care (improving 41/57 outcomes from 19 studies in three reviews); generally effective in improving referrals and admissions (improving 11/16 outcomes from 11 studies in four reviews); generally ineffective in improving compliance with guidelines outcomes (improving 5/17 outcomes from five studies in two reviews); and generally effective in improving prescribing costs outcomes (improving 28/34 outcomes from 10 studies in one review).

AUTHORS' CONCLUSIONS

Financial incentives may be effective in changing healthcare professional practice. The evidence has serious methodological limitations and is also very limited in its completeness and generalisability. We found no evidence from reviews that examined the effect of financial incentives on patient outcomes.

"All the money in the world …" patient perspectives regarding the influence of financial incentives

OBJECTIVE

To analyze patient perspectives of the use of financial incentives in a hypertension intervention. Study Setting. Twelve Veterans Affairs primary care clinics over a 9-month period.

STUDY DESIGN

Qualitative semistructured interviews conducted with 54 hypertensive veterans participating in an intervention to promote guideline-consistent therapy. Intervention components included an intervention letter requesting patients talk with their providers, an offer of U.S.$20 to bring in the letter to their provider, and a health educator phone call.

DATA COLLECTION METHODS

Semistructured interviews were conducted. Transcripts were coded for thematic content. The financial incentive theme was then subcoded for more detailed analysis.

PRINCIPLE FINDINGS

Most participants (n=48; 88.9 percent) stated the incentive had (or would have) no effect on their decision to initiate a discussion with their provider. Some participants articulated reservations about the effectiveness and/or appropriateness of financial incentives in health care decisions; however, a few expressed the opinion that there may be some potential benefits to the use of financial incentives if they encourage patients to be active in their health care.

CONCLUSION

The findings of this study raise questions about the appropriateness and unintended consequences of employing patient-directed financial incentives in health care settings.

[The life cycle of general practitioners' professional motivations: the case of prevention]

BACKGROUND

The analysis of "professional motivations", mainly through the possible crowding-out effects between extrinsic and intrinsic motivations, has become an issue of great concern in the economic literature. This paper aims at applying this topic to the healthcare professions where the proper scaling up of pay-for-performance (P4P) policies by public authorities is at stake.

METHODS

We used a panel of 528 self-employed general practitioners in the "Provence-Alpes-Côte d'Azur" region in France to provide an interpersonal statistical decomposition between extrinsic and intrinsic motivations with regard to preventive actions. Then, we applied a Tobit model in order to specify the main explicative variables of the share of intrinsic motivations entering into physicians' total motivations.

RESULTS

The relative share of intrinsic motivations was quite high among physicians paid with fixed fees. We found a significant effect of age on intrinsic motivations describing a U-shaped curve which can be interpreted as being the result of a "life cycle of medical motivations" or a generational effect.

CONCLUSION

The cross-sectional nature of the data does not allow us to draw any conclusions concerning the predominance of the generational effect or the "life cycle effect" on the evolution of the relative share of physician's intrinsic motivations. Nevertheless, the U-shaped relation between intrinsic motivations and age questions the suitability of using uniformly P4P mechanisms. The generations or age groups of self-employed physicians who seem to be less responsive to extrinsic motivations are more likely to favour the introduction of other types of payment schemes (capitation or salary systems) or regulation tools such as clinical practice guidelines.

An unhealthy public-private tension: pharmacy ownership, prescribing, and spending in the Philippines

Physicians' links with pharmacies may create perverse financial incentives to overprescribe, prescribe products with higher profit margins, and direct patients to their pharmacy. Interviews with pharmacy customers in the Philippines show that those who use pharmacies linked to public-sector physicians had 5.4 greater odds of having a prescription from such physicians and spent 49.3 percent more than customers using other pharmacies. For customers purchasing brand-name medicines, switching to generics would reduce drug spending by 58 percent. Controlling out-of-pocket spending on drugs requires policies to control financial links between doctors and pharmacies, as well as tighter regulation of nongeneric prescribing.

Medicaid payment mechanisms: impact on medication adherence and health care service utilization in type 2 diabetes enrollees

The purpose of this retrospective cohort study was to examine the impact of the type of health plan (capitated vs. fee for service [FFS]) on outcomes (medication adherence and health care service utilization) in type 2 diabetes Medicaid enrollees. Subjects were 8581 Medicaid enrollees with type 2 diabetes who newly started oral pharmacotherapy and were followed for 6 months before and 12 months after the index antidiabetic medication to collect data on medication adherence and health care service utilization. Multiple log-linear regression analysis was used to predict medication adherence while negative binomial regressions were used to examine health care service utilization. Medication adherence was found to be significantly lower for patients in capitated plans (5%, P < 0.05). Moreover, patients in capitated plans were associated with 14% more hospitalizations and 16% increased odds of emergency room visits, but 27% fewer outpatient visits compared to those in FFS plans (all P < 0.05). Although Medicaid programs use capitated managed care plans primarily as a cost-containment strategy, these plans may not be cost-effective for the long-term management of chronic conditions such as diabetes.

Systematic review: Effects, design choices, and context of pay-for-performance in health care

BACKGROUND

Pay-for-performance (P4P) is one of the primary tools used to support healthcare delivery reform. Substantial heterogeneity exists in the development and implementation of P4P in health care and its effects. This paper summarizes evidence, obtained from studies published between January 1990 and July 2009, concerning P4P effects, as well as evidence on the impact of design choices and contextual mediators on these effects. Effect domains include clinical effectiveness, access and equity, coordination and continuity, patient-centeredness, and cost-effectiveness.

METHODS

The systematic review made use of electronic database searching, reference screening, forward citation tracking and expert consultation. The following databases were searched: Cochrane Library, EconLit, Embase, Medline, PsychINFO, and Web of Science. Studies that evaluate P4P effects in primary care or acute hospital care medicine were included. Papers concerning other target groups or settings, having no empirical evaluation design or not complying with the P4P definition were excluded. According to study design nine validated quality appraisal tools and reporting statements were applied. Data were extracted and summarized into evidence tables independently by two reviewers.

RESULTS

One hundred twenty-eight evaluation studies provide a large body of evidence -to be interpreted with caution- concerning the effects of P4P on clinical effectiveness and equity of care. However, less evidence on the impact on coordination, continuity, patient-centeredness and cost-effectiveness was found. P4P effects can be judged to be encouraging or disappointing, depending on the primary mission of the P4P program: supporting minimal quality standards and/or boosting quality improvement. Moreover, the effects of P4P interventions varied according to design choices and characteristics of the context in which it was introduced.Future P4P programs should (1) select and define P4P targets on the basis of baseline room for improvement, (2) make use of process and (intermediary) outcome indicators as target measures, (3) involve stakeholders and communicate information about the programs thoroughly and directly, (4) implement a uniform P4P design across payers, (5) focus on both quality improvement and achievement, and (6) distribute incentives to the individual and/or team level.

CONCLUSIONS

P4P programs result in the full spectrum of possible effects for specific targets, from absent or negligible to strongly beneficial. Based on the evidence the review has provided further indications on how effect findings are likely to relate to P4P design choices and context. The provided best practice hypotheses should be tested in future research.

Measuring patients' assessments of primary care quality: the use of self-report questionnaires

The views of patients are seen as an increasingly important complement to other measures of quality of care, such as clinical indicators. This review summarizes previous research and current issues relating to the use of patient assessments of primary care quality. Patient assessments can be used to measure a number of different domains of primary care quality. Significant advances have been made in terms of the production of comprehensive, reliable and valid patient assessments, which can be used in both research and quality improvement activities. However, the effectiveness of the use of patient assessments as a technology for quality improvement remains unclear.

Priorities for research into human resources for health in low- and middle-income countries

OBJECTIVE

To identify the human resources for health (HRH) policy concerns and research priorities of key stakeholders in low- and middle-income countries; to assess the extent to which existing HRH research addresses these concerns and priorities; and to develop a prioritized list of core research questions requiring immediate attention to facilitate policy development and implementation.

METHODS

The study involved interviews with key informants, including health policy-makers, researchers and community and civil society representatives, in 24 low- and middle-income countries in four regions, a literature search for relevant reviews of research completed to date, and the assessment of interview and literature search findings at a consultative multinational workshop, during which research questions were prioritized.

FINDINGS

Twenty-one research questions emerged from the key informant interviews, many of which had received little or no attention in the reviewed literature. The questions ranked as most important at the consultative workshop were: (i) To what extent do incentives work in attracting and retaining qualified health workers in underserviced areas? (ii) What is the impact of dual practice and multiple employment? and (iii) How can incentives be used to optimize efficiency and the quality of health care?

CONCLUSION

There was a clear consensus about the type of HRH policy problems faced by different countries and the nature of evidence needed to tackle them. Coordinated action to support and implement research into the highest priority questions identified here could have a major impact on health worker policies and, ultimately, on the health of the poor.

Pay for performance: will dentistry follow?

BACKGROUND

"Pay for performance" is an incentive system that has been gaining acceptance in medicine and is currently being considered for implementation in dentistry. However, it remains unclear whether pay for performance can effect significant and lasting changes in provider behavior and quality of care. Provider acceptance will likely increase if pay for performance programs reward true quality. Therefore, we adopted a quality-oriented approach in reviewing those factors which could influence whether it will be embraced by the dental profession.

DISCUSSION

The factors contributing to the adoption of value-based purchasing were categorized according to the Donabedian quality of care framework. We identified the dental insurance market, the dental profession position, the organization of dental practice, and the dental patient involvement as structural factors influencing the way dental care is practiced and paid for. After considering variations in dental care and the early stage of development for evidence-based dentistry, the scarcity of outcome indicators, lack of clinical markers, inconsistent use of diagnostic codes and scarcity of electronic dental records, we concluded that, for pay for performance programs to be successfully implemented in dentistry, the dental profession and health services researchers should: 1) expand the knowledge base; 2) increase considerably evidence-based clinical guidelines; and 3) create evidence-based performance measures tied to existing clinical practice guidelines.

SUMMARY

In this paper, we explored factors that would influence the adoption of value-based purchasing programs in dentistry. Although none of these factors were essential deterrents for the implementation of pay for performance programs in medicine, the aggregate seems to indicate that significant changes are needed before this type of program could be considered a realistic option in dentistry.

Disentangling the impact of multiple innovations to reduce delayed hospital discharges

Delayed hospital discharges are often blamed for interrupting the smooth operation of hospitals. In England, the Community Care Act in 2003 introduced fines to social services departments to resolve this issue. Evaluations of this policy reported success in the reduction of delays. However, this policy was an amalgam of several innovations, not just the introduction of fines. This simultaneity makes attribution of impact of fines a difficult task because of the potential impact of those other measures. All the other designed organizational changes contain as much mechanisms of change as the more advertised fines. The exploration of how all these elements are connected unravels the inner workings of the programme as a whole, and by default, of the fines. This theoretical analysis also demonstrates how the reduction of some delays is based on the re-definition of key concepts for delayed discharges such as 'safe to transfer', team decision-making and causes for delays.

Incentive payments to general practitioners aimed at increasing opportunistic testing of young women for chlamydia: a pilot cluster randomised controlled trial

BACKGROUND

Financial incentives have been used for many years internationally to improve quality of care in general practice. The aim of this pilot study was to determine if offering general practitioners (GP) a small incentive payment per test would increase chlamydia testing in women aged 16 to 24 years, attending general practice.

METHODS

General practice clinics (n = 12) across Victoria, Australia, were cluster randomized to receive either a $AUD5 payment per chlamydia test or no payment for testing 16 to 24 year old women for chlamydia. Data were collected on the number of chlamydia tests and patient consultations undertaken by each GP over two time periods: 12 month pre-trial and 6 month trial period. The impact of the intervention was assessed using a mixed effects logistic regression model, accommodating for clustering at GP level.

RESULTS

Testing increased from 6.2% (95% CI: 4.2, 8.4) to 8.8% (95% CI: 4.8, 13.0) (p = 0.1) in the control group and from 11.5% (95% CI: 4.6, 18.5) to 13.4% (95% CI: 9.5, 17.5) (p = 0.4) in the intervention group. Overall, the intervention did not result in a significant increase in chlamydia testing in general practice. The odds ratio for an increase in testing in the intervention group compared to the control group was 0.9 (95% CI: 0.6, 1.2). Major barriers to increased chlamydia testing reported by GPs included a lack of time, difficulty in remembering to offer testing and a lack of patient awareness around testing.

CONCLUSIONS

A small financial incentive alone did not increase chlamydia testing among young women attending general practice. It is possible small incentive payments in conjunction with reminder and feedback systems may be effective, as may higher financial incentive payments. Further research is required to determine if financial incentives can increase testing in Australian general practice, the type and level of financial scheme required and whether incentives needs to be part of a multi-faceted package.

TRIAL REGISTRATION

Australian New Zealand Clinical Trial Registry ACTRN12608000499381.

Pharmaceutical cost control in primary care: opinion and contributions by healthcare professionals

Background

Strategies adopted by health administrations and directed towards drug cost control in primary care (PC) can, according to earlier studies, generate tension between health administrators and healthcare professionals. This study collects and analyzes the opinions of general practitioners (GPs) regarding current cost control measures as well as their proposals for improving the effectiveness of these measures.

Methods

A qualitative exploratory study was carried out using 11 focus groups composed of GPs from the Spanish regions of Aragon, Catalonia and the Balearic Islands. A semi-structured guide was applied in obtaining the GPs' opinions. The transcripts of the dialogues were analyzed by two investigators who independently considered categorical and thematic content. The results were supervised by other members of the team, with overall responsibility assigned to the team leader.

Results

GPs are conscious of their public responsibility with respect to pharmaceutical cost, but highlight the need to spread responsibility for cost control among the different actors of the health system. They insist on implementing measures to improve the quality of prescriptions, avoiding mere quantitative evaluations of prescription costs. They also suggest moving towards the self-management of the pharmaceutical budget by each health centre itself, as a means to design personalized incentives to improve their outcomes. These proposals need to be considered by the health administration in order to pre-empt the feelings of injustice, impotence, frustration and lack of motivation that currently exist among GPs as a result of the implemented measures.

Conclusion

Future investigations should be oriented toward strategies that involve GPs in the planning and management of drug cost control mechanisms. The proposals in this study may be considered by the health administration as a means to move toward the rational use of drugs while avoiding concerns about injustice and feelings of impotence on the part of the GPs, which can lead to lack of interest in and disaffection with the current measures.

From public to private and back again: sustaining a high service-delivery level during transition of management authority: a Cambodia case study

Contracting non-governmental organizations (NGOs) has been shown to increase health service delivery output considerably over relatively short time frames in low-income countries, especially when applying performance-related pay as a stimulus. A key concern is how to manage the transition back to government-operated systems while maintaining health service delivery output levels. In this paper we describe and analyse the transition from NGO-managed to government-managed health services over a 3-year period in a health district in Cambodia with a focus on the level of health service delivery. Data are derived from four sources, including cross-sectional surveys and health management and financial information systems. The transition was achieved by focusing on all the building blocks of the health care system and ensuring an acceptable financial remuneration for the staff members of contracted health facilities. The latter was attained through performance subsidies derived from financial commitment by the central government, and revenue from user fees. Performance management had a crucial role in the gradual handover of responsibilities. Not all responsibilities were handed back to government over the case study period-notably the development of performance indicators and targets and the performance monitoring.

The effects of an incentive program on quality of care in diabetes management

An incentive program for general practitioners to encourage systematic and igh-quality care in chronic disease management was introduced in Australia in 1999. There is little empirical evidence and ambiguous theoretical guidance on which effects to expect. This paper evaluates the impact of the incentive program on quality of care in diabetes, as measured by the probability of ordering an HbA1c test. The empirical analysis is conducted with a unique data set and a bivariate probit model to control for the self-selection process of practices into the program. The study finds that the incentive program increased the probability of an HbA1c test being ordered by 20 percentage points and that participation in the program is facilitated by the support of Divisions of General Practice.

Does competition among general practitioners increase or decrease the consumption of specialist health care?

Studies of the effects of capacity and competition among general practitioners (GPs) on the use of specialist health care services are inconclusive. Some studies indicate that an increase in the number of GPs leads to increased consumption of specialist health care, while other studies point in the opposite direction. This article adds to the literature in two ways; first by testing out different operationalization of capacity and competition among GPs, and then by testing out effects of capacity and competition on use of specialist health care services as this is disaggregated into ambulatory and inpatient activities. The empirical tests indicate that GP capacity in itself does not affect use of specialist health care services. Increased competitions among GPs do, however, reduce the use of ambulatory care while the effects on the use of inpatient services are unaffected.

Can paying for results help to achieve the Millennium Development Goals? Overview of the effectiveness of results-based financing

OBJECTIVE

Results-based financing and pay-for-performance refer to the transfer of money or material goods conditional on taking a measurable action or achieving a predetermined performance target. Results-based financing is widely advocated for achieving health goals, including the Millennium Development Goals.

METHODS

We undertook an overview of systematic reviews of the effectiveness of RBF. We searched the Cochrane Library, EMBASE, and MEDLINE (up to August 2007). We also searched for related articles in PubMed, checked the reference lists of retrieved articles, and contacted key informants. We included reviews with a methods section that addressed the effects of any results-based financing in the health sector targeted at patients, providers, organizations, or governments. We summarized the characteristics and findings of each review using a structured format.

RESULTS

We found 12 systematic reviews that met our inclusion criteria. Based on the findings of these reviews, financial incentives targeting recipients of health care and individual healthcare professionals are effective in the short run for simple and distinct, well-defined behavioral goals. There is less evidence that financial incentives can sustain long-term changes. Conditional cash transfers to poor and disadvantaged groups in Latin America are effective at increasing the uptake of some preventive services. There is otherwise very limited evidence of the effects of results-based financing in low- or middle-income countries. Results-based financing can have undesirable effects, including motivating unintended behaviors, distortions (ignoring important tasks that are not rewarded with incentives), gaming (improving or cheating on reporting rather than improving performance), widening the resource gap between rich and poor, and dependency on financial incentives.

CONCLUSION

There is limited evidence of the effectiveness of results-based financing and almost no evidence of the cost-effectiveness of results-based financing. Based on the available evidence and likely mechanisms through which financial incentives work, they are more likely to influence discrete individual behaviors in the short run and less likely to create sustained changes.

Does your health care depend on how your insurer pays providers? Variation in utilization and outcomes in Thailand

Hospitals in Thailand operate in a multiple insurance payment environment. This paper examines (1) access to medicines and other medical technologies, (2) treatment outcomes, and (3) efficiency in resource use, among beneficiaries of the three government health insurance schemes in Thailand. Using 2003-2005 outpatient and inpatient data for patients with three tracer diseases from three government hospitals, we find that utilization of more expensive items differs between patients whose insurers pay on a closed- or open-ended basis. Where new vs. conventional drugs are both available, patients whose insurer pays on a fee-for-service basis tend to have greater access to new drugs, compared to patients whose insurer pays on a capitated or case basis. Similar patterns were found where there are options between originator versus generic drugs, drugs in different dosage forms, and more versus less advanced diagnostic technologies. Effects of insurance payment are more pronounced where price gaps among the medical technologies are significant. Efficiency results are mixed, depending on nature of the disease conditions and type of resources required for treatment.

Social network analysis in primary care: the impact of interactions on prescribing behaviour

OBJECTIVES

In many healthcare systems of affluent countries, general practitioners (GPs) are encouraged to work in collaborative arrangements to increase patients' accessibility and the quality of care. There are two lines of thought regarding the ways in which belonging to a network can affect GP behaviour: (1) the social capital framework posits that, through relationships, individuals acquire resources, such as information, that allow them to perform better; and (2) the social influence framework sees relationships as avenues through which individual actors influence other individuals and through which behavioural norms are developed and enforced. The objective of this study is to provide an evaluation of the effects of GP network organisation on their prescribing behaviour.

METHODS

We used administrative data from a Local Health Authority (LHA) in Italy concerning GPs organisation and prescriptions.

RESULTS

We found that GPs working in a collaborative arrangement have a similar prescribing behaviour while we did not find a significant relationship between the centrality of a GP and her capability to meet LHA's targets.

CONCLUSIONS

Our data support the conclusion that, in the case of GP collaboration initiatives, the social influence mechanism is more relevant than the social capital mechanism.

Do list size and remuneration affect GPs' decisions about how they provide consultations?

BACKGROUND

Doctors' professional behaviour is influenced by the way they are paid. When GPs are paid per item, i.e., on a fee-for-service basis (FFS), there is a clear relationship between workload and income: more work means more money. In the case of capitation based payment, workload is not directly linked to income since the fees per patient are fixed. In this study list size was considered as an indicator for workload and we investigated how list size and remuneration affect GP decisions about how they provide consultations. The main objectives of this study were to investigate a) how list size is related to consultation length, waiting time to get an appointment, and the likelihood that GPs conduct home visits and b) to what extent the relationships between list size and these three variables are affected by remuneration.

METHODS

List size was used because this is an important determinant of objective workload. List size was corrected for number of older patients and patients who lived in deprived areas. We focussed on three dependent variables that we expected to be related to remuneration and list size: consultation length; waiting time to get an appointment; and home visits. Data were derived from the second Dutch National Survey of General Practice (DNSGP-2), carried out between 2000 and 2002. The data were collected using electronic medical records, videotaped consultations and postal surveys. Multilevel regression analyses were performed to assess the hypothesized relationships.

RESULTS

Our results indicate that list size is negatively related to consultation length, especially among GPs with relatively large lists. A correlation between list size and waiting time to get an appointment, and a correlation between list size and the likelihood of a home visit were only found for GPs with small practices. These correlations are modified by the proportion of patients for whom GPs receive capitation fees. Waiting times to get an appointment tend to become shorter with increasing patient lists when there is a larger capitation percentage. The likelihood that GPs will conduct home visit rises with increasing patient lists when the capitation percentage is small.

CONCLUSION

Remuneration appears to affect GPs' decisions about how they provide consultations, especially among GPs with relatively small patient lists. This role is, however, small compared to other factors such as patient characteristics.

Soft regulations in pharmaceutical policy making: an overview of current approaches and their consequences

It is a challenge to improve public health within limited resources. Pharmaceutical policy making is a greater challenge due to conflicting interests between key stakeholder groups. This paper reviews current and future strategies to help improve the quality and efficiency of care, with special emphasis on demand-side controls for pharmaceutical prescribing. A large number of different educational, organizational, financial and regulatory strategies have been applied in pharmaceutical policy making. However, the effectiveness of most strategies has not been thoroughly evaluated and there is evidence that the behaviour of healthcare professionals is difficult to influence with traditional methods. During the last decades, new modes of governing and new governing constellations have also appeared in healthcare. However, relationships between those who regulate and those regulated are often unclear. New approaches have recently been introduced, including extensive dissemination strategies for guidelines and extensive quality assessment programmes where physicians' performances are measured against agreed standards or against each other. The main components of these 'soft regulations' are standardization, monitoring and agenda setting. However, the impact of these new modes on health provision and overall costs is often unknown, and the increased focus on monitoring may result in a higher conformity and uniformity that may not always benefit all key stakeholders. Alongside this, a substantial growth of auditing associations controlling a diminishing minority of people actually performing the tasks may be costly and counter-productive. As a result, new effective strategies are urgently needed to help maintain comprehensive healthcare without prohibitively raising taxes or insurance premiums. This is especially important where countries are faced with extreme financial problems. Healthcare researchers may benefit from researching other areas of society. However, any potential strategies initiated must be adequately researched, debated and evaluated to enhance implementation. We hope this opinion paper is the first step in the process to develop and implement new demand-side initiatives building on existing 'soft regulations'.

Empowering women to obtain high quality care: evidence from an evaluation of Mexico's conditional cash transfer programme

OBJECTIVES

To evaluate the impact of Mexico's conditional cash transfer programme on the quality of health care received by poor women. Quality is measured by maternal reports of prenatal care procedures received that correspond with clinical guidelines.

METHODS

The data describe retrospective reports of care received from 892 women in poor rural communities in seven Mexican states. The women were participating in an effectiveness study and randomly assigned to incorporation into the programme in 1998 or 1999. Eligible women accepted cash transfers conditional on obtaining health care and nutritional supplements, and participated in health education sessions.

RESULTS

Oportunidades beneficiaries received 12.2% more prenatal procedures compared with non-beneficiaries (adjusted mean 78.9, 95% Confidence Interval (CI): 77.5-80.3; P < 0.001).

CONCLUSION

The Oportunidades conditional cash transfer programme is associated with better quality of prenatal care for low-income, rural women in Mexico. This result is probably a manifestation of the programme's empowerment goal, by encouraging beneficiaries to be informed and active health consumers.

Do physician remuneration schemes matter? The case of Canadian family physicians

Although it is well known theoretically that physicians respond to financial incentives, the empirical evidence is quite mixed. Using the 2004 Canadian National Physician Survey, we analyze the number of patient visits per week provided by family physicians in alternative forms of remuneration schemes. Overwhelmingly, fee-for-service (FFS) physicians conduct more patient visits relative to four other types of remuneration schemes examined in this paper. We find that family physicians self-select into different remuneration regimes based on their personal preferences and unobserved characteristics; OLS estimates plus the estimates from an IV GMM procedure are used to tease out the magnitude of the selection and incentive effects. We find a positive selection effect and a large negative incentive effect; the magnitude of the incentive effect increases with the degree of deviation from a FFS scheme. Knowledge of the extent to which remuneration schemes affect physician output is an important consideration for health policy.

Effects of payment for performance in primary care: qualitative interview study

OBJECTIVES

To understand the effects of a large scale 'payment for performance' scheme (the Quality and Outcomes Framework [QOF]) on professional roles and the delivery of primary care in the English National Health Service.

METHODS

Qualitative semi-structured interview study. Twenty-four clinicians were interviewed during 2006: one general practitioner and one practice nurse in 12 general practices in eastern England with a broad range of sociodemographic and organizational characteristics.

RESULTS

Participants reported substantial improvements in teamwork and in the organization, consistency and recording of care for conditions incentivized in the scheme, but not for non-incentivized conditions. The need to carry out and record specific clinical activities was felt to have changed the emphasis from 'patient led' consultations and listening to patients' concerns. Loss of continuity of care and of patient choice were described. Nurses experienced increased workload but enjoyed more autonomy and job satisfaction. Doctors acknowledged improved disease management and teamwork but expressed unease about 'box-ticking' and increased demands of team supervision, despite better terms and conditions. Doctors were less motivated to achieve performance indicators where they disputed the evidence on which they were based. Participants expressed little engagement with results of patient surveys or patient involvement initiatives. Some participants described data manipulation to maximize practice income. Many felt overwhelmed by the flow of policy initiatives.

CONCLUSIONS

Payment for performance is driving major changes in the roles and organization of English primary health care teams. Non-incentivized activities and patients' concerns may receive less clinical attention. Practitioners would benefit from improved dissemination of the evidence justifying the inclusion of new performance indicators in the QOF.

Provision of Domiciliary Dental Care in North and West Belfast

Aim

To determine the level of domiciliary care currently provided for patients by general dental practitioners (GDPs) and to investigate factors that influence the provision of domiciliary dental care in an area of high socioeconomic deprivation in North and West Belfast.

Method

A descriptive study, involving a self-administered postal questionnaire sent to GDPs (n=89) in North and West Belfast.

Results

A valid response rate of 67% was achieved. Almost 20% of responding GDPs reported that they did not routinely offer domiciliary dental care. Of those who did, prosthetic treatment was undertaken most commonly, and other more time-consuming treatments such as fillings were referred to the Community Dental Services (CDS). Many GDPs reported not having a full range of domiciliary equipment, with only half of the GDPs surveyed carrying emergency drugs. Reasons cited for not providing the service were lack of time, the perception that patients would be too difficult to manage, and not having the appropriate equipment. The majority of responding dentists (85%) felt that domiciliary care should be referred to the community service.

Conclusion

The rate of domiciliary care provision in North and West Belfast appears to be falling, despite it being an area of high socioeconomic deprivation where the demand for the service is growing. The general perception was that domiciliary care is too time-consuming, that the patients are too difficult to manage, and that there was a lack of appropriate equipment. As a result, the majority of GDPs in North and West Belfast felt that the CDS should care for all domiciliary patients.

Control and performance of health care systems. A comparative analysis of 19 OECD countries

This paper performs an empirical comparison of health systems. Health systems are seen as networks of delegation relationships among principals and agents, subject to agency problems. Following the institutional economics approach, a health system's efficiency is considered to be determined by the existence and treatment of agency problems. Agency problems can be controlled by mechanisms built into the health system, or can also be controlled by an external actor, for example, the government, either by using the instruments available or by conducting institutional reforms. To explain differences in the amenability of a country's health system to external governmental control, I combine the veto player approach and the incentives for societal actors to exert influence, into the concept of indirect veto players: the more indirect veto players exist, the less external control will be exercised.I derive indicators capturing both forms of control and perform a comparison of health systems based on institutional and performance data. Using data reducing methods, I identify two dimensions of control underlying the institutional setting of the health system and three dimensions of health system performance. The relationships found between control and performance confirm the hypotheses derived from the adopted theoretical approach.

Diversity in diabetes care programmes and views on high quality diabetes care: are we in need of a standardized framework?

OBJECTIVES

To explore views on high quality diabetes care based on an analysis of existing diversity in diabetes care programmes and related quality indicators.

METHODS

A review of systematic reviews was performed. Four databases (MEDLINE database of the National Library of Medicine, COCHRANE database of Systematic Reviews, the Cumulative Index to Nursing and Allied Health Database-CINAHL and Pre-Cinahl) were searched for English review articles published between November 1989 and December 2006. Methodological quality of the articles was assessed. A standardized extraction form was used to assess features of diabetes care programmes and diabetes quality indicators with special reference to those aspects that hinder the conceptualization of high quality diabetes care. Based on these findings the relationship between diversity in diabetes care programmes and the conceptualization of high quality diabetes care was further explored.

RESULTS

Twenty-one systematic reviews met the inclusion criteria representing a total of 185 diabetes care programmes. Six elements were identified to produce a picture of diversity in diabetes care programmes and hinder their standardization: 1) the variety and relative absence of conceptual backgrounds in diabetes care programmes, 2) confusion over what is considered a constituent of a diabetes care program and components of the implementation strategy, 3) large variety in type of diabetes care programmes, settings and related goals, 4) a large number and variety in interventions and quality indicators used, 5) no conclusive evidence on effectiveness, 6) no systematic results on costs.

CONCLUSIONS

There is large diversity in diabetes care programmes and related quality indicators. From this review and our analysis on the mutual relationship between diversity in diabetes care programmes and the conceptualization of high quality diabetes care, we conclude that no single conceptual framework used to date provides a comprehensive overview of attributes of high quality diabetes care linked to quality indicators at the structure, process and outcome level. There is a need for a concerted action to develop a standardized framework on high quality diabetes care that is complemented by a practical tool to provide guidance to the design, implementation and evaluation of diabetes care programmes.

Selecting effective incentive structures in health care: A decision framework to support health care purchasers in finding the right incentives to drive performance

BACKGROUND

The Ontario health care system is devolving planning and funding authority to community based organizations and moving from steering through rules and regulations to steering on performance. As part of this transformation, the Ontario Ministry of Health and Long-Term Care (MOHLTC) are interested in using incentives as a strategy to ensure alignment - that is, health service providers' goals are in accord with the goals of the health system. The objective of the study was to develop a decision framework to assist policymakers in choosing and designing effective incentive systems.

METHODS

The first part of the study was an extensive review of the literature to identify incentives models that are used in the various health care systems and their effectiveness. The second part was the development of policy principles to ensure that the used incentive models are congruent with the values of the Ontario health care system. The principles were developed by reviewing the Ontario policy documents and through discussions with policymakers. The validation of the principles and the suggested incentive models for use in Ontario took place at two meetings. The first meeting was with experts from the research and policy community, the second with senior policymakers from the MOHLTC. Based on the outcome of those two meetings, the researchers built a decision framework for incentives. The framework was send to the participants of both meetings and four additional experts for validation.

RESULTS

We identified several models that have proven, with a varying degree of evidence, to be effective in changing or enabling a health provider's performance. Overall, the literature suggests that there is no single best approach to create incentives yet and the ability of financial and non-financial incentives to achieve results depends on a number of contextual elements. After assessing the initial set of incentive models on their congruence with the four policy principles we defined nine incentive models to be appropriate for use in Ontario and potentially other health care systems that want to introduce incentives to improve performance. Subsequently, the models were incorporated in the resulting decision framework.

CONCLUSION

The design of an incentive must reflect the values and goals of the health care system, be well matched to the performance objectives and reflect a range of contextual factors that can influence the effectiveness of even well-designed incentives. As a consequence, a single policy recommendation around incentives is inappropriate. The decision framework provides health care policymakers and purchasers with a tool to support the selection of an incentive model that is the most appropriate to improve the targeted performance.

Effects of policy options for human resources for health: an analysis of systematic reviews

BACKGROUND

Policy makers face challenges to ensure an appropriate supply and distribution of trained health workers and to manage their performance in delivery of services, especially in countries with low and middle incomes. We aimed to identify all available policy options to address human resources for health in such countries, and to assess the effectiveness of these policy options.

METHODS

We searched Medline and Embase from 1979 to September, 2006, the Cochrane Library, and the Human Resources for Health Global Resource Center database. We also searched up to 10 years of archives from five relevant journals, and consulted experts. We included systematic reviews in English which assessed the effects of policy options that could affect the training, distribution, regulation, financing, management, organisation, or performance of health workers. Two reviewers independently assessed each review for eligibility and quality, and systematically extracted data about main effects. We also assessed whether the policy options were equitable in their effects; suitable for scaling up; and applicable to countries with low and middle incomes.

FINDINGS

28 of the 759 systematic reviews of effects that we identified were eligible according to our criteria. Of these, only a few included studies from countries with low and middle incomes, and some reviews were of low quality. Most evidence focused on organisational mechanisms for human resources, such as substitution or shifting tasks between different types of health workers, or extension of their roles; performance-enhancing strategies such as quality improvement or continuing education strategies; promotion of teamwork; and changes to workflow. Of all policy options, the use of lay health workers had the greatest proportion of reviews in countries with a range of incomes, from high to low.

INTERPRETATION

We have identified a need for more systematic reviews on the effects of policy options to improve human resources for health in countries with low and middle incomes, for assessments of any interventions that policy makers introduce to plan and manage human resources for health, and for other research to aid policy makers in these countries.

Reduced in-hospital mortality after improved management of children under 5 years admitted to hospital with malaria: randomised trial

OBJECTIVE

To test whether strict implementation of a standardised protocol for the management of malaria and provision of a financial incentive for health workers reduced mortality.

DESIGN

Randomised controlled intervention trial.

SETTING

Paediatric ward at the national hospital in Guinea-Bissau. All children admitted to hospital with severe malaria received free drug kits.

PARTICIPANTS

951 children aged 3 months to 5 years admitted to hospital with a diagnosis of malaria randomised to normal or intervention wards.

INTERVENTIONS

Before the start of the study, all personnel were trained in the use of the standardised guidelines for the management of malaria, including strict follow-up procedures. Nurses and doctors were randomised to work on intervention or control wards. Personnel in the intervention ward received a small financial incentive ($50 (25 pounds sterling; 35 euros)/month for nurses and $160 for doctors) and their compliance with standard case management was closely monitored.

MAIN OUTCOME MEASURES

In-hospital mortality and cumulative mortality within 4 weeks of hospital admission.

RESULTS

In-hospital mortality was 5% for the intervention group and 10% in the control group (risk ratio 0.48, 95% confidence interval 0.29 to 0.79). The effect may have been stronger in patients with positive malaria slides (0.36, 0.16 to 0.80). Cumulative mortality 4 weeks after discharge was also lower in the intervention group (0.61, 0.40 to 0.95).

CONCLUSIONS

Supervising healthcare workers to adhere to a standardised treatment protocol was associated with greatly reduced in-hospital mortality. Financial incentives may be important for the dedication and compliance of staff members.

TRIAL REGISTRATION

Clinical Trials NCT00465777 [ClinicalTrials.gov].

Pharmaceutical policies: effects of financial incentives for prescribers

BACKGROUND

Pharmaceuticals, while central to medical therapy, pose a significant burden to health care budgets. Therefore regulations to control prescribing costs and improve quality of care are implemented increasingly. These include the use of financial incentives for prescribers, namely increased financial accountability using budgets and performance based payments.

OBJECTIVES

To determine the effects on drug use, healthcare utilisation, health outcomes and costs (expenditures) of policies, that intend to affect prescribers by means of financial incentives.

SEARCH STRATEGY

We searched the following databases and web sites: Effective Practice and Organisation of Care Group Register (August 2003), Cochrane Central Register of Controlled Trials (October 2003), MEDLINE (October 2005), EMBASE (October 2005), and other databases.

SELECTION CRITERIA

Policies were defined as laws, rules, financial and administrative orders made by governments, non-government organisations or private insurers. One of the following outcomes had to be reported: drug use, healthcare utilisation, health outcomes, and costs. The study had to be a randomised or non-randomised controlled trial, interrupted time series analysis, repeated measures study or controlled before-after study evaluating financial incentives for prescribers introduced for a jurisdiction or healthcare system.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study limitations.

MAIN RESULTS

Thirteen evaluations of budgetary policies and none of performance based payments met our inclusion criteria. Ten studies evaluated general practice fundholding in the UK, one the Irish Indicative Drug Target Savings Scheme (IDTSS) and two evaluated German drug budgets for physicians in private practice. The interrupted time series analyses had some limitations. All the controlled before-after studies (all from the UK) had serious limitations. Drug expenditure (per item and per patient) and prescribed drug volume decreased with budgets in all three countries. Evidence indicated increased use of generic drugs in the UK and Ireland, but was inconclusive on the use of new and expensive drugs. We found no clear evidence of increased health care utilisation and no studies reporting effects on health. Administration costs were not reported. No studies on the effects of performance-based payments or other policies met our inclusion criteria.

AUTHORS' CONCLUSIONS

Based on the evidence in this review from three Western European countries, drug budgets for physicians in private practice can limit drug expenditure by limiting the volume of prescribed drugs, increasing the use of generic drugs or both. Since the majority of studies included were found to have serious limitations, these results should be interpreted with care.

Prescribing for chronic heart failure in Europe: does the country make the difference? A European survey

PURPOSE

International differences in prescribing patterns for chronic heart failure (CHF) have been demonstrated repeatedly. It is not clear whether these differences arise entirely from patient characteristics or factors related to the country itself, such as health care systems or culture. We aim to assess the role of countries in this international variation, aside from the role of patient characteristics.

METHODS

In this European primary care practice survey (from 1999/2000) 11062 CHF patients from 14 countries were included. The influence of country (corrected for patient characteristics) on prescribed drug regimes was assessed by multinomial logistical regression.

RESULTS

Prescribing of guideline-recommended drug regimes ranged from 28.1% in Turkey to 61.8% in Hungary. Including additional regimes justifiable by patients' co-morbidities, increased overall 'rational' prescribing by 11%, but differences among countries remained similar. Multivariate analysis for one-drug and two-drug regimes explained between 35% and 42% of the total variance, country contributed 7%-8% (p < 0.005). Countries determined the number of drugs used and the likelihood of individual drug regimes. For example, in Czech Republic digoxin alone was more likely to be given than the recommended ACE-inhibitors (OR: 3.45; 95%CI: 2.56-4.64), while the combination of digoxin with ACE-inhibitors was as likely as the recommended combination of ACE-inhibitors and beta-blockers (OR: 1.17; 95%CI: 0.88-1.55).

CONCLUSION

Country of residence clearly influenced prescribed drug volume and choice of drug regimes. Therefore, optimal CHF management cannot be achieved without considering country specific factors. It remains to be established which factors within health-care systems are responsible for these effects.

Effects of a behaviour independent financial incentive on prescribing behaviour of general practitioners

RATIONALE AND OBJECTIVES

It is difficult to keep control over prescribing behaviour in general practice. The purpose of this study was to assess the initial effects of a behaviour independent financial incentive on the volume of drug prescribing of general practitioners (GPs).

DESIGN

2-Year Controlled Before After study with an intervention region and a concurrent control region.

SETTING AND PARTICIPANTS

GPs in two regions in the Netherlands (n = 119 and n = 118).

INTERVENTION

A financial incentive for prescribing according to local guidelines on specific drugs or drug categories. The financial incentive consisted of a non-recurrent, behaviour-independent allowance.

MAIN OUTCOME MEASURE

Change in the number of prescriptions for 10 targeted drugs or drug groups.

RESULTS

Significant changes were seen only in three types of antibiotics and in recommended gastric medicines. In almost all cases, effects were temporary.

CONCLUSION

Behaviour independent financial incentives can be a help in changing prescription behaviour of GPs, but effects are small-scale and temporary.

Predictors of the growing influence of clinical practice guidelines

BACKGROUND

Despite the proliferation of clinical practice guidelines (CPGs), physicians have been slow to adopt them.

OBJECTIVE

Describe changes in the reported effect of CPGs on physicians' clinical practice over the past decade, and identify the practice characteristics associated with those changes.

DESIGN AND PARTICIPANTS

Longitudinal and cross-sectional analyses of rounds 1-4 of the Community Tracking Study Physician Survey, a nationally representative survey, conducted periodically between 1996 and 2005.

MEASUREMENTS

The cross-sectional outcome was the reported effect of CPGs on the physician's practice (very large, large, moderate, small, very small, and no effect). The longitudinal outcome was the change in reported effect of CPGs between two consecutive rounds for panel respondents. Independent variables included changes in physicians' practice characteristics (size, ownership, capitation, availability of information technology (IT) to access guidelines, whether quality measures and profiling affect compensation, and revenue sources).

RESULTS

The proportion of primary care physicians reporting that CPGs had a very large or large effect on their practice increased significantly from 1997 to 2005, from 16.4% to 38.7% (P < .0001). The corresponding change for specialists was 18.9% to 28.2% (P < .0001). In longitudinal multivariate analyses, practice characteristics associated with an increase in effect of CPGs included acquiring IT to access guidelines, an increase in the impact that quality measures and profiling have on compensation, and an increase in the proportion of practice revenue under capitation or derived from Medicaid.

CONCLUSIONS

Promotion of wider adoption of health IT, and financial incentives linked to validated quality measures, may facilitate further growth in the impact of CPGs.

Physician Perceptions of Access to Quality Care in California's Workers' Compensation System

OBJECTIVE

We measured the association of physician perceptions of access to quality care with intentions to change workers' compensation (WC) participation levels, barriers to delivery of quality care, levels of payment, and type of provider after the implementation of California WC reforms in 2004.

METHODS

Bivariate and logistic regression models were employed using a representative survey of WC providers.

RESULTS

The analyses revealed that intentions to quit or decrease the volume of WC patients, reporting utilization review as a barrier to quality care, and being a chiropractor or acupuncturist were significantly associated with perceptions of decline in access or quality since 2004 and the belief that injured workers do not have access to quality care.

CONCLUSIONS

The results indicate specific aspects of WC reform that lead to negative perceptions among providers and require further scrutiny and improvement.

Planning and studying improvement in patient care: the use of theoretical perspectives

A consistent finding in articles on quality improvement in health care is that change is difficult to achieve. According to the research literature, the majority of interventions are targeted at health care professionals. But success in achieving change may be influenced by factors other than those relating to individual professionals, and theories may help explain whether change is possible. This article argues for a more systematic use of theories in planning and evaluating quality-improvement interventions in clinical practice. It demonstrates how different theories can be used to generate testable hypotheses regarding factors that influence the implementation of change, and it shows how different theoretical assumptions lead to different quality-improvement strategies.

A behavioral model of clinician responses to incentives to improve quality

The use of pay for performance (P4P) and public reporting of performance (PR) in health care is increasing rapidly worldwide. The rationale for P4P and PR comes from experience in other industries and from theories about incentive use from psychology, economics, and organizational behavior. This paper reviews the major themes from this prior research and considers how they might be applied to health care. The resulting conceptual model addresses the dual nature (combining direct financial and reputational incentives) of the initiatives many policymakers are pursuing. It also includes explicit recognition of the key contextual factors (at the levels of the markets and the provider organization) and provider and patient characteristics that can enhance or mitigate response to incentives. Evaluation of the existing literature (through June 2005) about incentive use in health care in light of the conceptual model highlights important weaknesses in the way that trials have been reported to date and suggests future research topics.