NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

AHRQ Evidence Report Summaries. Rockville (MD): Agency for Healthcare Research and Quality (US); 1998-2005.

This publication is provided for historical reference only and the information may be out of date.

Bookshelf ID: NBK11845

101 Economic Incentives for Preventive Care: Summary

RL Kane, PE Johnson, RJ Town, and M Butler.

Current as of August 2004.

Introduction

The Institute of Medicine's (IOM) recent Quality Chasm report suggests that the U.S. health care system requires major reengineering, including

major realignment of incentives, if health care is to provide collaborative quality care and care management and effectively prevent and manage

chronic disease.1 Growing recognition of this need for realignment has led to "pay for quality" initiatives for providers and a parallel search for

effective economic interventions for consumer health behavior change.2Similar "pay for prevention" initiatives are used to address the gap

between the high cost of preventable disease and deaths3and the actual practices of health providers and consumers. These initiatives use

explicit, or extrinsic, incentives such as bonuses and cash or other in-kind financial incentives for providers and consumers to engage in

specific preventive care or health promotion practices. The question is whether such economic incentives are a useful approach.

In this report, we evaluate evidence from the literature on the impact of explicit economic incentives targeted at motivating providers and

consumers to adopt preventive health behaviors. The review is designed to:

Help develop more effective preventive strategies (evidence-based practice).

Help inform key stakeholders about the role of such practices (evidence-based policymaking).

In collaboration with AHRQ, the key research questions identified were:

Key Question 1: How have "preventive care" and "economic incentive" been defined in the literature?

Key Question 2: Do incentives work?

Key Question 3: Is there evidence of a dose/response curve?

Key Question 4: What is the evidence for cost-effectiveness of economic incentive interventions?

Definition of Prevention

In the current environment of growing chronic illness burden and improving identification of risk factors for major diseases such as heart

disease, the boundaries between primary, secondary, and tertiary prevention begin to blur. For example, high cholesterol and hypertension,

though risk factors, are identified as treatable conditions. However, the purpose of treating high cholesterol is prevention of full-blown heart

disease.

For the purposes of this report, we defined preventive care and health promotion as those situations in which consumers may consider

themselves healthy or physically at risk but have not yet been labeled with a diagnosis. This includes individual-based health promotion and

preventives services as defined in Healthy People 2000 and 20104, 5but excludes mental health, substance abuse, and health protection

concerns such as injury prevention, occupational health and safety, environmental health, and oral health. Tertiary care, including self-care and

diagnosed chronic illnesses such as diabetes and heart disease, was also excluded. We included clinical and non-clinical settings, such as

worksite and community-based health promotion settings.

Disease prevention and health promotion cover a wide spectrum of behaviors for both consumers and providers, from simple, one-time

vaccinations to complex behavioral changes such as weight control. For the purposes of this review, we define a complex preventive concern

as one that requires sustained effort over time on the part of the patient/consumer.

Definition of Economic Incentives

This review examines explicit incentives targeted at specific individuals, either providers or consumers. Incentives offered to providers could

include direct payments or bonuses to the provider or his/her group. It was expected that economic incentives would vary considerably by the

nature of the incentive, the components involved, size, frequency, duration, and the conditions that triggered payment of the incentive. More

diffuse incentives offered as part of managed care (e.g., waiving co-payments) were excluded for both consumers and providers because of the

difficulty in pinpointing their specific effect. Consumer incentives are fairly straightforward and include cash, gifts, lotteries, and other free or

reduced price goods and services for the benefit of the specific consumer.

Methods

Literature Search and Data Abstraction

MEDLINE®, EconLit, Business Source Premier, and PsychInfo were the online reference databases used to conduct the literature review.

PsychInfo, EconLit, and Business Source Premier were approached with a simple strategy of combining keyword searches for "incent$" and

"health."

Reference lists of previous systematic reviews and identified articles were reviewed for other relevant studies. We also searched the Cochrane

Collaboration database.

English-language articles published between 1966 and 2002 that addressed behaviors related to prevention as defined above were included in

the review. We excluded studies that related to patient adherence to drug therapy or chronic illness management. We also excluded multiple

component intervention studies in which the economic incentive was only one component and the study design precluded analyzing the

Economic Incentives for Preventive Care: Summary - AHRQ Evide... http://www.ncbi.nlm.nih.gov/books/NBK11845/?report=printable

1 of 7 09/19/12 11:42 AM
independent effect of the incentive. In all, nine articles were included in the provider-incentive structured literature review, and 47 were included

in the consumer review.

A data abstraction form was devised during the initial stages of the literature search. Formal meta-analysis of the incentive literature was not

possible because of insufficient numbers of studies that examined the same incentive type, research outcome measures, and similar

populations. The abstraction form was created with the purpose of facilitating the ability to capture emergent themes from the heterogeneous

literature. Abstraction of the articles was performed by two independent reviewers. Disagreements were resolved by consensus of the group.

Results

All 9 provider incentive studies addressed simple preventive concerns:

6 articles examined immunizations.6-

11

2 looked at cancer screening.12, 13

1 looked at prenatal care.14

1 looked at well-child visits.10

1 examined cholesterol screening.6

Note: Numbers do not add to 9 as 2 studies used more than one preventive care measure as an outcome.

Twenty-four of the 47 consumer articles were classified as simple prevention:

7 on immunization.15-

21

2 on cancer screening.22, 23

2 on prenatal care.24, 25

3 on attendance at educational sessions for STD/HIV prevention.26-

28

1 on recruitment for a smoking cessation program.29

9 on preventive care followup:

Cholesterol screening.30

Tuberculosis screening,31, 32

Cancer screening.33-

36

Post-partum exams.37, 38

Twenty-three articles addressed complex preventive care concerns:

10 on smoking cessation.39-

48

2 on exercise.49, 50

7 on obesity and weight loss.43, 51-

56

1 each on breastfeeding,57 nutrition,58 cardiovascular disease prevention,59 and cholesterol management.60

Key Question 1

In general, definitions for "prevention" and "economic incentive" are not specifically addressed in the literature. The term "economic incentives"

is used to describe financial incentives. Such incentives include a wide variety of actions. For providers these included bonus payments

payable on the basis of number of inputs used or based on the provider achieving a target outcome or target behavior. For consumers, the

incentives took the form of cash payments, lotteries, coupons for free or reduced price goods and services, gifts, free or reduced price medical

services, and the opportunity to avoid disincentives.

Key Question 2

Provider

All incentives were aimed at physicians; non-physician staff were not targeted. Reports were not clear on whether the financial incentives were

paid to the physician or the practice. Incented physicians included family practitioners, general practitioners, internists, and pediatricians. All

studies took place in nonacademic solo and group practices. However, "group" was often left undefined. Patient populations for 5 of the 9

studies were vulnerable populations.

Seven studies used bonuses potentially payable to all physicians.6-

9,11,13, 14 The remaining two studies were paid in tournament style.10,12

Only a few studies provided data on the bonus payment average size and range. Of those reporting, potential payments ranged from $50 to a

tournament bonus of $4,682. No study provided information on payment frequency or timing, nor on the investment costs the physician incurred

establishing the clinical and office procedures necessary to support the production and behavioral changes. Therefore, we could not assess

how these factors, plus the anticipated bonus program time period, impacted the physician's calculation of the incentive's potential overall

financial benefit.

No study provided information on the physicians' expectations of receiving a bonus. Overall awareness of the bonus program was low in two

studies that examined physician awareness.10,12

Economic Incentives for Preventive Care: Summary - AHRQ Evide... http://www.ncbi.nlm.nih.gov/books/NBK11845/?report=printable

2 of 7 09/19/12 11:42 AM
Eight studies used performance bonuses that rewarded the physician for achieving a target outcome.6

-

13 Two studies also included a per-input

bonus based on actual immunizations provided.8, 9

Study outcomes were primarily measured as the percent of charts in compliance with a target outcome. Charts were generally classified

compliant if the preventive service was documented as having occurred regardless of whether the preventive service was provided by the

physician or his/her office staff or provided elsewhere.

Findings for the studies were mixed; overall four found positive effects6-

9

and five found no effects.10-

14 Improvements in chart documentation

procedures may account for the positive effects. Positive effects were found in three subgroup analyses for group practice settings.10-

12

Not all studies reported effect sizes or provided adequate information to construct relative risk ratios. Attempts to contact lead authors to obtain

such information met with limited success. Based on the information provided, the effect size is moderate at best. For example, in one study

receiving economic incentives was associated with a 7.1 percent increase in immunization rates.7

Consumer

Patient populations tended to fall into 2 broad categories that correlated with the simple/complex classification. Vulnerable populations of low

socioeconomic status, the first category, were the most frequently studied populations for simple preventive care such as immunizations and

cancer screening and followup, constituting 16 of the 24 simple preventive studies but only 4 of the 23 complex studies. These populations

included active drug users, teen mothers, low-income children with mothers in the Women, Infants and Children or Aid to Families with

Dependent Children programs, and patients of public clinics and safety-net hospitals. These populations were also considered at high risk for

the study's targeted health concern. By contrast, generally healthy, middle-class populations recruited from work sites or the general population

were the most frequent recruitment bases for studies of complex health promotion lifestyle changes.

Very few reports outlined a clear link between the design of the economic incentive and the specific population intended to receive the

incentive. Only 3 studies justified the design of the chosen economic incentive.19,28,38 Only 9 studies directly tested the uptake of an

incentive.15, 16, 24,29,33,40,45, 53,58 Another 10 studies used different intervention arms to test the desirability of the incentive.18,24,26 ,28, 31,

32,38,45,5 5, 56

The type and size of the 59 incentives offered in the 47 studies varied extensively:

10 lotteries.

7 gifts.

11 cash incentives.

15 coupons for free or reduced price goods or non-medical services.

6 free or reduced price medical services.

10 incentives involving negative reinforcement or the opportunity to avoid punishment.

Seventy-eight percent of incentives required a target behavior from the participant as a condition for incentive distribution. The remainder

required the participant to attain a particular outcome. Several studies included additional intervention components, particularly social

pressures, which potentially confound the impact of the incentive.

All of the simple preventive care studies used hard outcome measures. Complex preventive care studies used self-report in some instances.

Whereas smoking cessation has available well established, valid, and reliable laboratory tests to confirm self-reported abstinence, directly

observing many relevant lifestyle behavior changes related to health promotion, such as exercise and eating patterns, is difficult.

Facilitating incentives designed to make engaging in the new behavior easier, including structural barrier removal, and studies using

disincentives showed significant effects. Incentives as rewards for participating and adhering to goals, whether for simple or complex

prevention, are in general effective inducements for behavior change. Most studies matched a short-term incentive with a short-term behavioral

change or outcome. While many of the studies in the outcome and negative reinforcement categories showed positive effects in the short run, of

the 4 studies that checked for long-term results, all of the significantly improved measures had returned to their original levels.42 ,47,48, 59

Key Question 3

We could not address dose response for provider incentives given the limited number of studies. There is minimal evidence of a dose

response within the consumer research. Cash incentives have the expected rank ordering. Coupons, more convenient and flexible, may be

preferred to gifts. Both studies that pitted a coupon incentive against a gift incentive found the coupon more effective.25,38 In addition, while

coupon incentives were effective, with 12 of 15 incentives showing positive results, only 4 of 7 gift incentives had positive results, and 2 of the

positive results were potentially confounded by additional lottery or competition intervention components. Indeed, some coupons were never

redeemed.

Key Question 4

Provider

No study addressed cost-effectiveness. One study calculated an intervention cost of $3 per additional immunization.7

Consumer

Only 7 of the 47 studies included cost-effectiveness calculations for the study itself. In 5 of the 7 cases, a treatment arm that consisted of a

similar intervention without the incentive itself was reported to be a more cost-effective approach. No study included an attempt to generalize

cost-effectiveness over time for the estimated impact of the incentive on potential population morbidity or mortality.

Discussion

Economic Incentives for Preventive Care: Summary - AHRQ Evide... http://www.ncbi.nlm.nih.gov/books/NBK11845/?report=printable

3 of 7 09/19/12 11:42 AM
Findings

The basic findings of the review for the 4 key questions can be summarized as follows:

Key Question 1

Definitions for economic incentives are not emphasized in the literature, not only in terms of locating the incentive intervention within larger

environmental contexts, but also with regard to the function of the incentive. That is, if the incentive fails to distinguish its goal as an external

reinforcement of behaviors until such time as the individual's internal motivation is sufficient, as a reinforcement until habituation or until some

learning task is accomplished, or simply as a means of directing a person's attention to a neglected area. As a whole, the studies lack a clear

conceptual context to delineate what an incentive is, its intended purpose, and how it is hypothesized to impact the individual.

In general, research appears to be driven by policy considerations. Policy guidelines developed by national organizations, expert panels, and

governmental bodies at the Federal and State levels provide the goals which in turn determine the operational definitions of preventive care.

While advancing understanding for specific health conditions and constituencies, this motivation results in a fragmented research agenda,

which inhibits transferring the gains across varied preventive domains.

Key Question 2

Provider

The literature is scarce. There is little evidence available to support the idea that explicit provider financial incentives, particularly of the modest

and artificial nature that were evaluated in the studies, are effective. Further, it appears that bonuses do not work simply and easily. The core

beliefs regarding the appropriateness and efficacy of financial incentives have only recently begun to be subjected to examination through either

experimentation or well-designed quasi-experimental or observational studies.

While there was some evidence that incentive effects were larger for group practices than solo practices, there is not enough information to sort

out the causes. The improvements could signal increased staff and office system resources available to group practices. As it is not clear

whether the incentives were paid directly to the physician or to the group, the question remains open.

Consumer

We may guardedly say that economic incentives are effective in the short run for simple preventive care and well defined, distinct behavioral

interventions. There is insufficient evidence to say that economic incentives are effective for long-term lifestyle changes required for health

promotion.

Key Question 3

The reviewed literature cannot answer whether there is a dose response for provider incentives, although one may assume that a sizable

enough incentive should produce the desired behavior, if at a high cost. There is a possible dose response for consumer incentives. Even more

interesting for consumer incentives is the effectiveness of relatively modest incentives. The threshold dose appears low.

Key Question 4

None of the provider studies and few of the consumer studies undertook to make this calculation, thus it is difficult for us to assess the net

predicted benefit of a given financial incentive.

Overall, the scientific quality of the current evidence is fair. While many studies were adequately designed to address the specific research

question, the question itself was often uninformative.

Practical Implications

Concerns over the quality of care have prompted increasing attention to how to change providers' behaviors.1Educational strategies such as

guidelines and protocols alone have not proven particularly successful.1 Economic incentives seem a more direct approach, but this review

raises several cautionary flags. The desired behaviors must be very specific and easy to track. Complex rules for success are less effective.

The incentive must be of sufficient size to make it worthwhile for the provider to change practice behaviors. In general, offering a chance to win a

large prize may be less attractive than the promise of a modest but substantial prize. Moreover, relying on incentives may prove dangerous

because it may foster dependency on them. If the provider behaviors are not ingrained, they may disappear when the incentives end or when a

new topic is selected to be incentivized.

Those planning to use incentives should be very clear about their goals. Is this intended as a temporary change in behavior or an inducement to

make a permanent change? Practitioners feel under great stress and harried by many competing demands for their time. Incentives may buy a

temporary priority from the provider, but sustained change in the operation of the practice will require an investment of energy to address the

underlying mechanisms that can reinforce the desired behaviors.

One might hope that a brief experience in delivering care in a new way, fostered by financial incentives, might lead to permanent changes in the

modus operandi of the practice, but there is little empirical evidence to support this hope. Some incentives may be permanent, a direct reward

to doing a defined task. Under those conditions, the necessary shifts in practice behavior may be incorporated, but it may be possible to

catalyze this transition by studying the logistics of the practice. In many cases, the critical actions rely on simple changes to prompt actions and

delegation of authority to support staff. In those cases, the resources earmarked for incentives may be put to more efficient use elsewhere.

The enthusiasm for consumer incentives may be driven by some of the same concerns. Pressures to improve preventive performance may

motivate some health care organizations to induce their enrollees to become more active in their own care and health promotion activities. In

some cases, it may be possible to simultaneously incent both consumers and providers towards synergistic ends. Consumers seem to be

more susceptible to incentives, even modest ones. At least some patients may appreciate the attention that incentive programs represent.

However, there is always a temptation to pick the low hanging fruit. The recalcitrant consumers may not be as easily swayed by incentives. The

energy required to reach and persuade non-adherent patients may still be high.

Future Research

Economic Incentives for Preventive Care: Summary - AHRQ Evide... http://www.ncbi.nlm.nih.gov/books/NBK11845/?report=printable

4 of 7 09/19/12 11:42 AM
Overall

The limited success of modest and "artificial" incentives to induce long-term change supports the current push for multi-component interventions

based on the full environmental or social ecological perspectives such as the McKinley model.2There is a need for further studies.58

Future researchers need to be clear about the causal chain of prevention or health promotion under investigation and the purpose of the

incentive intervention being considered. Evidence of this clarity is demonstrated in careful definitions of the process of care for a given

preventive concern; careful matching of the nature of the economic incentive in terms of type, size, duration, frequency, and the use of other

components such as education, social support or competition; and the projected long-term effects of the intervention once the incentive is

withdrawn.

The large literatures in the social and behavioral sciences on incentives should be brought to bear on the empirical questions of when, to whom,

and how much. Without theoretical underpinning it is difficult to understand exactly why incentives did or didn't work.

How economic incentives compare to and complement other strategies to improve preventive care, particularly with regard to long-term effects,

remains to be fully understood. Within multi-component research there may be joint effects between incentives and other components. Do

explicit incentives improve or impede, or are they unnecessary when a larger ecological effort is made, especially for consumers?

Natural settings for incentive research are important. The potential cost-effectiveness of incentives would be compromised if any positive

results of an incentive were so fragile that they survived only in controlled settings.

Mixed-method research projects would improve our understanding of the meaning and value of the incentives to the populations for which they

are intended and the attitudes and beliefs those populations hold.

Personality research and other ways to understand individual differences may provide insights toward understanding and addressing the

problem at which the incentive is aimed. Cultural differences should be more specifically examined.

Different types and sizes of economic incentives may trigger different modes of decisionmaking processes. We do not understand how a

targeted individual determines when psychological or economic decisionmaking models are used.

Providers

Which metric to use for determining if preventive care is under-provided from an economic perspective remains unresolved. Possible

perspectives are cost-effectiveness, effectiveness, consumer welfare, HMO welfare, or the opportunity cost of other types of care.

Consideration needs to be given to the organizations in which physicians work. Organizational dynamics affect the financial incentives and the

rules under which physicians practice. Economic incentives do not exist in a vacuum.

Consideration also needs to be given to measurement issues. Incentives must be based on things that can be measured, which then create the

potential for slackening of effort in other unmeasurable but potentially important domains of care. Paying provider incentives on health outcome

measures becomes a default choice when we cannot measure the process. We are often unable to determine with confidence what a unit of

preventive services is. Furthermore, success in prevention is generally a nonevent. It is much easier to count something that does occur than to

estimate the number of events that might have occurred but did not.

Attention should also be paid to teasing out the differential effects of 2 major components of economic incentives for physicians: motivation and

information content.

Future researchers should also keep in mind that scalability matters. For an incentive system to be widely put to use, it has to be large enough

to make the task seem worthwhile. We know little about how large such incentives need to be.

Consumers

Researchers need to address the potential for the coercive effect of incentives on patient autonomy. No study has investigated this concern.

Competitions, or tournaments, as a work-site economic incentive program component, need more testing before widescale adoption.

Provider Consumer Interaction

Future research should investigate possible synergistic effects of coordinated incentives simultaneously applied to both providers and

consumers for a particular preventive concern. The patient-provider relationship itself is also important. There is extensive literature in this area

to inform future research on the potential impact of incentives on the consumer's acceptance of the provider as a collaborator in health

promotion activities. In turn, providers may become more enthusiastic about a preventive activity when they are aware that it is being offered at

lower costs to their patients.

Conclusion

If we accept the value of preventive efforts, we must recognize the inadequacies of existing systems to encourage such practices. The literature

reviewed here suggests that financial incentives have been used, in an uncoordinated fashion, at three levels in an attempt to increase

prevention behaviors:

As motivators in the larger economic context of the health plan level, where savings associated with prevention are believed to be

efficient, or where market interventions have instituted preventive care performance measures as quality indicators.

As provider incentives to induce discrete behavioral changes.

As consumer incentives to remove barriers, improve health education, and reward healthy behavior.

System-level economic incentives can help to change the larger health care environment, in turn prompting the individual providers and

consumers to adapt to a new environment. Financial incentives, if they are big enough, can influence discrete behavior at the individual level in

the short run. The benefits of such incentives may be magnified if they are coordinated with each other and with system level incentives,

although this potential synergy remains untested. Whereas provider incentives do work, they may not provide a sustained behavior change.

There is always a danger that they will be displaced by a new set targeted at a new topic. So questions remain regarding whether investing in

office system changes which support long-term changes in practice is a better choice than relying on incentives. More importantly, since various

Economic Incentives for Preventive Care: Summary - AHRQ Evide... http://www.ncbi.nlm.nih.gov/books/NBK11845/?report=printable

5 of 7 09/19/12 11:42 AM
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

26.

27.

28.

observers have noted that the business case for quality improvement is still weak, we must ask who is prepared to bear the cost of either

strategy.

Availability of Full Report

The full evidence report from which this summary was taken was prepared for AHRQ by the University of Minnesota Evidence-based Practice

Center under Contract No. 290-02-0009. Printed copies may be obtained free of charge from the AHRQ Publications Clearinghouse by calling

800-358-9295. Requesters should ask for Evidence Report/Technology Assessment No. 101, Economic Incentives for Preventive Care.

The Evidence Report can also be downloaded as a set of PDF files.

AHRQ Publication Number 04-E024-1

Current as of August 2004

Internet Citation:

Kane RL, Johnson PE, Town RJ, et al. Economic Incentives for Preventive Care. Summary, Evidence Report/Technology Assessment:

Number 101. AHRQ Publication Number 04-E024-1, August 2004. Agency for Healthcare Research and Quality, Rockville, MD.

http://www.ahrq.gov/clinic/epcsums/ecincsum.htm

References

Institute of Medicine. Crossing the Quality Chasm: A NewHealth System for the 21st Century. Washington, DC: National Academy Press;

2001.

Casalino L, Gillies RR, Shortell SM. et al. External incentives, information technology, and organized processes to improve health care

quality for patients with chronic diseases. JAMA. 2003;289(4):434–41. [PubMed: 12533122]

McGinnis JM, Foege WH. Actual causes of death in the United States. JAMA. 1993;270(18):2207–12. [PubMed: 8411605]

U.S. Department of Health and Human Services. Healthy People 2000: national health promotion and disease prevention objectives.

Washington, DC: U.S. Department of Health and Human Services, Public Health Service; 1991. 91-50212.

U.S. Department of Health and Human Services. Healthy People 2010. Washington, DC: U.S. Department of Health and Human Services;

2000.

Morrow RW, Gooding AD, Clark C. Improving physicians' preventive health care behavior through peer review and financial incentives. Arch

Fam Med. 1995;4(2):165–9. [PubMed: 7842155]

Kouides RW, Bennett NM, Lewis B. et al. Performance-based physician reimbursement and influenza immunization rates in the elderly. The

Primary-Care Physicians of Monroe County. Am J Prev Med. 1998;14(2):89–95. [PubMed: 9631159]

Fairbrother G, Hanson KL, Friedman S. et al. The impact of physician bonuses, enhanced fees, and feedback on childhood immunization

coverage rates. Am J Public Health. 1999;89(2):171–5. [PMC free article: PMC1508536] [PubMed: 9949744]

Fairbrother G, Siegel MJ, Friedman S. et al. Impact of financial incentives on documented immunization rates in the inner city: results of a

randomized controlled trial. Ambul Pediatr. 2001;1(4):206–12. [PubMed: 11888402]

Hillman AL, Ripley K, Goldfarb N. et al. The use of physician financial incentives and feedback to improve pediatric preventive care in

Medicaid managed care. Pediatrics. 1999;104(4 Pt 1):931–5. [PubMed: 10506237]

Ritchie LD, Bisset AF, Russell D. et al. Primary and preschool immunisation in Grampian: progress and the 1990 contract. BMJ.

1992;304(6830):816–9. [PMC free article: PMC1881680] [PubMed: 1392710]

Hillman AL, Ripley K, Goldfarb N. et al. Physician financial incentives and feedback: failure to increase cancer screening in Medicaid

managed care. Am J Public Health. 1998;88(11):1699–701. [PMC free article: PMC1508575] [PubMed: 9807540]

Grady KE, Lemkau JP, Lee NR. et al. Enhancing mammography referral in primary care. Prev Med. 1997;26(6):791–800. [PubMed:

9388790]

Fox MH, Phua KL. Do increases in payments for obstetrical deliveries affect prenatal care? Public Health Rep. 1995;110(3):319–26.

[PMC free article: PMC1382127] [PubMed: 7610224]

Nexoe J, Kragstrup J, Ronne T. Impact of postal invitations and user fee on influenza vaccination rates among the elderly. A randomized

controlled trial in general practice. Scand J Prim Health Care. 1997;15(2):109–12. [PubMed: 9232713]

Satterthwaite P. A randomised intervention study to examine the effect on immunisation coverage of making influenza vaccine available at

no cost. NZ Med J. 1997;110(1038):58–60.

Birkhead GS, LeBaron CW, Parsons P. et al. The immunization of children enrolled in the Special Supplemental Food Program for

Women, Infants, and Children (WIC). JAMA. 1995;274(4):312–6. [PubMed: 7609260]

Yokley JM, Glenwick DS. Increasing the immunization of preschool children; an evaluation of applied community interventions. J Appl

Behav Anal. 1984;17(3):313–25. [PMC free article: PMC1307948] [PubMed: 6439714]

Moran WP, Nelson K, Wofford JL. et al. Increasing influenza immunization among high-risk patients: education or financial incentive? Am J

Med. 1996;101(6):612–20. [PubMed: 9003108]

Hutchins SS, Rosenthal J, Eason P. et al. Effectiveness and cost-effectiveness of linking the special supplemental program for women,

infants, and children (WIC) and immunization activities. J Public Health Policy. 1999;20(4):408–26. [PubMed: 10643168]

Kerpelman LC, Connell DB, Gunn WJ. Effect of a monetary sanction on immunization rates of recipients of aid to families with dependent

children. JAMA. 2000;284(1):53–9. [PubMed: 10872013]

Mayer JA, Kellogg MC. Promoting mammography appointment making. J Behav Med. 1989;12(6):605–11. [PubMed: 2634113]

Mayer JA, Clapp EJ, Bartholomew S. et al. Facility-based in reach strategies to promote annual mammograms. Am J Prev Med.

1994;10(6):353–6. [PubMed: 7880555]

Laken MP, Ager J. Using incentives to increase participation in prenatal care. Obstet Gynecol. 1995;85(3):326–9. [PubMed: 7862366]

Melnikow J, Paliescheskey M, Stewart GK. Effect of a transportation incentive on compliance with the first prenatal appointment: a

randomized trial. Obstet Gynecol. 1997;89(6):1023–7. [PubMed: 9170485]

Deren S, Stephens R, Davis WR. et al. The impact of providing incentives for attendance at AIDS prevention sessions. Public Health Rep.

1994;109(4):548–54. [PMC free article: PMC1403532] [PubMed: 8041855]

Dahl DW, Gorn GJ, Weinberg CB. Encouraging use of coupons to stimulate condom purchase. Am J Public Health. 1999;89(12):1866–9.

[PMC free article: PMC1509018] [PubMed: 10589320]

Kamb ML, Rhodes F, Hoxworth T. et al. What about money? Effect of small monetary incentives on enrollment, retention, and motivation to

change behaviour in an HIV/STD prevention counselling intervention. The Project RESPECT Study Group. Sex Transm Infect.

Economic Incentives for Preventive Care: Summary - AHRQ Evide... http://www.ncbi.nlm.nih.gov/books/NBK11845/?report=printable

6 of 7 09/19/12 11:42 AM
29.

30.

31.

32.

33.

34.

35.

36.

37.

38.

39.

40.

41.

42.

43.

44.

45.

46.

47.

48.

49.

50.

51.

52.

53.

54.

55.

56.

57.

58.

59.

60.

1998;74(4):253–5. [PMC free article: PMC1758123] [PubMed: 9924463]

Emont SL, Cummings KM. Using a low-cost, prize-drawing incentive to improve recruitment rate at a work-site smoking cessation clinic. J

Occup Med. 1992;34(8):771–4. [PubMed: 1506933]

Owen N, James R, Henrikson D. et al. Community cholesterol screenings: The impact of follow-up letters and incentives on retest rates

and biometric changes in follow-up screenings. Am J Health Promotion. 1990;5(1):58–61.

Malotte CK, Hollingshead JR, Rhodes F. Monetary versus nonmonetary incentives for TB skin test reading among drug users. Am J Prev

Med. 1999;16(3):182–8. [PubMed: 10198656]

Malotte CK, Rhodes F, Mais KE. Tuberculosis screening and compliance with return for skin test reading among active drug users. Am J

Public Health. 1998;88(5):792–6. [PMC free article: PMC1508952] [PubMed: 9585747]

Freedman JD, Mitchell CK. A simple strategy to improve patient adherence to outpatient fecal occult blood testing. J Gen Intern Med.

1994;9(8):462–4. [PubMed: 7965243]

Marcus AC, Crane LA, Kaplan CP. et al. Improving adherence to screening follow-up among women with abnormal Pap smears: results

from a large clinic-based trial of three intervention strategies. Med Care. 1992;30(3):216–30. [PubMed: 1538610]

Marcus AC, Kaplan CP, Crane LA. et al. Reducing loss-to-follow-up among women with abnormal Pap smears. Results from a

randomized trial testing an intensive follow-up protocol and economic incentives. Med Care. 1998;36(3):397–410. [PubMed: 9520963]

Kaplan CP, Bastani R, Belin TR. et al. Improving follow-up after an abnormal pap smear: results from a quasi-experimental intervention

study. J Womens Health Gender-Based Med. 2000;9(7):779–90.

Stevens-Simon C, O'Connor P, Bassford K. Incentives enhance postpartum compliance among adolescent prenatal patients. J Adolesc

Health. 1994;15(5):396–9. [PubMed: 7947854]

Smith PB, Weinman ML, Johnson TC. et al. Incentives and their influence on appointment compliance in a teenage family-planning clinic. J

Adolesc Health Care. 1990;11(5):445–8. [PubMed: 2211279]

Dey P, Foy R, Woodman M. et al. Should smoking cessation cost a packet? A pilot randomized controlled trial of the cost-effectiveness of

distributing nicotine therapy free of charge. Br J Gen Pract. 1999;49(439):127–8. [PMC free article: PMC1313349] [PubMed: 10326267]

Hughes JR, Wadland WC, Fenwick JW. et al. Effect of cost on the self-administration and efficacy of nicotine gum: a preliminary study.

Prev Med. 1991;20(4):486–96. [PubMed: 1908080]

Windsor RA, Lowe JB, Bartlett EE. The effectiveness of a worksite self-help smoking cessation program: a randomized trial. J Behav

Med. 1988;11(4):407–21. [PubMed: 3070047]

Koffman DM, Lee JW, Hopp JW. et al. The impact of including incentives and competition in a workplace smoking cessation program on

quit rates. Am J Health Promotion. 1998;13(2):105–11.

Jeffery RW, Forster JL, French SA. et al. The Healthy Worker Project: a work-site intervention for weight control and smoking cessation.

Am J Public Health. 1993;83(3):395–401. [PMC free article: PMC1694637] [PubMed: 8438979]

Donatelle RJ, Prows SL, Champeau D, et al. Randomised controlled trial using social support and financial incentives for high risk

pregnant smokers: significant other supporter (SOS) program. Tob Control 2000;9(Suppl 3):III67-9.

Stitzer ML, Bigelow GE. Contingent payment for carbon monoxide reduction: Effects of pay amount. Behav Ther. 1983;14(5):647–56.

Gottlieb NH, Nelson A. A systematic effort to reduce smoking at the worksite. Health Educ Quarterly. 1990;17(1):99–118.

Curry SJ, Wagner EH, Grothaus LC. Evaluation of intrinsic and extrinsic motivation interventions with a self-help smoking cessation

program. J Consult Clin Psych. 1991;59(2):318–24.

Klesges RC, Glasgow RE, Klesges LM. et al. Competition and relapse prevention training in worksite smoking modification. Health Educ

Res. 1987;2(1):5–14.

Wing RR, Jeffery RW, Pronk N. et al. Effects of a personal trainer and financial incentives on exercise adherence in overweight women in a

behavioral weight loss program. Obes Res. 1996;4(5):457–62. [PubMed: 8885210]

Harland J, White M, Drinkwater C. et al. The Newcastle exercise project: a randomised controlled trial of methods to promote physical

activity in primary care.[comment] BMJ. 1999;319(7213):828–32. [PMC free article: PMC314213] [PubMed: 10496829]

Jeffery RW, French SA. Preventing weight gain in adults: the pound of prevention study. Am J Public Health. 1999;89(5):747–51. [PMC

free article: PMC1508711] [PubMed: 10224988]

Jeffery RW, Wing RR, Thorson C. et al. Use of personal trainers and financial incentives to increase exercise in a behavioral weight-loss

program. J Consult Clin Psych. 1998;66(5):777–83.

Follick MJ, Fowler JL, Brown RA. Attrition in worksite weight-loss interventions: the effects of an incentive procedure. J Consult Clin Psych.

1984;52(1):139–40.

Jeffery RW, Thompson PD, Wing RR. Effects on weight reduction of strong monetary contracts for calorie restriction or weight loss. Behav

Res Ther. 1978;16(5):363–9. [PubMed: 743075]

Jeffery RW. et al. Effectiveness of monetary contracts with two repayment schedules of weight reduction in men and women from

self-referred and population samples. Behav Ther. 1984;15(3):273–9.

Jeffery RW, Gerber WM, Rosenthal BS. et al. Monetary contracts in weight control: effectiveness of group and individual contracts of

varying size. J Consult Clin Psych. 1983;51(2):242–8.

Sciacca JP, Phipps BL, Dube DA. et al. Influences on breast-feeding by lower-income women: an incentive-based, partner-supported

educational program. J Am Diet Assoc. 1995;95(3):323–8. [PubMed: 7860944]

Anderson JV, Bybee DI, Brown RM. et al. 5 a day fruit and vegetable intervention improves consumption in a low income population. J Am

Diet Assoc. 2001;101(2):195–202. [PubMed: 11271692]

Gomel M, Oldenburg B, Simpson JM. et al. Work-site cardiovascular risk reduction: a randomized trial of health risk assessment,

education, counseling, and incentives. Am J Public Health. 1993;83(9):1231–8. [PMC free article: PMC1694995] [PubMed: 8362997]

Francisco VT, Paine AL, Fawcett SB. et al. An experimental evaluation of an incentive program to reduce serum cholesterol levels among

health fair participants. Arch Fam Med. 1994;3(3):246–51. [PubMed: 8180714]

AHRQ Publication Number 04-E024-1

Copyright Notice: This publication is in the public domain. For more information, see the Bookshelf Copyright Notice.

Economic Incentives for Preventive Care: Summary - AHRQ Evide... http://www.ncbi.nlm.nih.gov/books/NBK11845/?report=printable

7 of 7 09/19/12 11:42 AM