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# Economic Incentives for Preventive Care

*Evidence Reports/Technology Assessments, No. 101*

Investigators: Robert L Kane, MD, Paul E Johnson, PhD, Robert J Town, PhD, and Mary Butler, MBA.

Agency for Healthcare Research and Quality (US)2004 Aug
Report No.: 04-E024-21-58763-162-8

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## Structured Abstract

#### Context:

In recent years “pay for prevention” initiatives have beendevised to address gaps between the high cost of preventable disease and deaths andthe actual prevention practices of health providers and consumers. These initiativesuse explicit, or extrinsic, incentives such as bonuses and cash or other in-kindfinancial incentives for providers and consumers to engage in specific preventivecare or health promotion practices. The question is whether such economic incentivesare a useful approach. In this report, we evaluate evidence from the literature onthe impact of economic incentives targeted at providers and consumers on preventivehealth behaviors. The review is designed to 1) help develop more effectivepreventive strategies (evidence-based practice), and 2) help inform key stakeholdersabout the role of such practices, (evidence-based policymaking).

#### Objectives:

A systematic review of the literature was undertaken toaddress four questions:

Key Question 1 - How have “preventive care” and “economic incentive” been defined inthe 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 incentiveinterventions?

#### Data Sources:

We identified MEDLINE® , the Cochrane Library,EconLit, Business Source Premier, and PsychINFO as the literature sources for thisreview. Reference lists from previous systematic reviews, including the CochraneLibrary were also examined as well. We also culled relevant articles from referencelists of identified studies.

#### Study Selection:

Articles for both provider and consumer incentiveswere subjected to the inclusion and exclusion criteria. Individual articles must beprimary studies in which preventive care or health promotion was a primary outcomemeasure. Preventive care was defined as care prior to illness diagnosis, thusexcluding adherence studies. Also excluded were studies which included multiplefactors in addition to economic incentives within the intervention arm, as werestudies examining payment forms provided by more than one payment system, ie, HMOvs. FFS (as there are too many potential confounding factors). We included onlyRCTs, time series, and prospective quasi-experimental designs for the structuredliterature reviews. However, we also provided information from relativelywell-designed econometric cross-sectional studies for the provider incentives asanother perspective for consideration. Nineteen articles passed the inclusioncriteria for provider economic incentives, and 47 articles passed the criteria forthe consumer economic incentives.

#### Data Extraction:

The abstraction tool was created with the purpose offacilitating the ability to capture emergent themes from the heterogeneousliterature. The form was reviewed and commented on by the TEP members, piloted, andsubsequently revised. Abstraction of the articles was performed by two independentreviewers. Disagreements were resolved by consensus of the group.

#### Data Synthesis:

Formal meta-analysis of the incentive literature wasnot possible because there were not a large number of studies that examined the sameincentive type, research outcome measures, and similar populations. General trendswere summarized.

#### Conclusions:

Definitions for neither “prevention” nor “economicincentive” are specifically addressed in the literature. Research on the effects ofincentive interventions on preventive care and health promotion appears to be drivenby policy considerations. Definitions for preventive care and economic incentivesare not emphasized in the literature, not only in terms of locating the incentiveintervention within larger environmental contexts, but also with regard to thefunction of the incentive.

There is little evidence available to support the idea that explicit providerfinancial incentives, particularly of the modest and artificial nature that wereevaluated in the studies, are effective. Further, it appears bonuses do not worksimply and easily. In the short run, consumer economic incentives are effective forsimple preventive care and distinct behavioral goals that are well defined. Thereisn't sufficient evidence at this time to say that economic incentives are effectivefor promoting the long-term lifestyle changes required for health promotion.

The reviewed literature cannot answer whether there is a dose response for providerincentives, although one may assume that a sizable enough incentive should producethe desired behavior, if at a high cost. There is a possible dose response forconsumer incentives. Even more interesting for consumer incentives is theeffectiveness of relatively modest incentives. The threshold dose appears low.

None of the provider studies and few of the consumer studies undertook to make thiscalculation, thus it is difficult for us to assess the net predicted benefit of agiven financial incentive.

Overall, the scientific quality of the current evidence is fair. While many studieswere adequately designed to address the specific research question, the questionitself was often uninformative.

## Contents

                          - Expand All
                          - Collapse All

                        - Preface
                        - Acknowledgments
                        - 1. Introduction                           - Overview
                          - Background
                        - 2. Methods                           - Solicitation of Input and Data
                          - Literature Search
                          - Abstraction
                          - Emergent Themes
                          - Rating Strength of the Evidence
                          - Peer Review Process
                        - 3. Results                           - Simple vs. Complex Prevention
                        - 4. Discussion                           - Key Question 1. Definitions
                          - Key Question 2. Do Incentives Work?
                          - Key Question 3. Dose Response
                          - Key Question 4. Cost-Effectiveness
                          - Other Perspectives
                          - General Discussion
                          - Practical Implications
                          - Limitations
                          - Future Research
                        - Appendix A. Technical Expert Panel Members and Reviewers
                        - Appendix B. Exact Search Strings
                        - Appendix C. Screening Form
                        - Appendix D. Abstraction Forms
                        - Appendix E. Algorithm
                        - Appendix F. Evidence Tables Continued
                        - References and Included Studies
                        - Listing of Excluded Studies

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                          - Collapse All

1

#### Suggested citation:

Kane RL, Johnson PE, Town RJ, Butler M. EconomicIncentives for Preventive Care. Evidence Report/Technology Assessment No. 101(Prepared by the University of Minnesota Evidence-based Practice Center underContract No. 290-02-0009.) AHRQ Publication No. 04-E024-2. Rockville, MD. Agencyfor Healthcare Research and Quality. August 2004.

This report may be used, in whole or in part, as the basis for development ofclinical practice guidelines and other quality enhancement tools, or a basis forreimbursement and coverage policies. AHRQ or U.S. Department of Health and HumanServices endorsement of such derivative products may not be stated or implied.

AHRQ is the lead Federal agency charged with supporting research designed to improvethe quality of health care, reduce its cost, address patient safety and medicalerrors, and broaden access to essential services. AHRQ sponsors and conductsresearch that provides evidence-based information on health care outcomes; quality;and cost, use, and access. The information helps health care decisionmakers—patientsand clinicians, health system leaders, and policymakers—make more informed decisionsand improve the quality of health care services.

The authors of this report are responsible for its content. Statements in the reportshould not be construed as endorsement by the Agency for Healthcare Research andQuality or the U.S. Department of Health and Human Services of a particular drug,device, test, treatment, or other clinical service.

                        - 1
                        - 
540 Gaither Road, Rockville, MD 20850. www​.ahrq.gov

Copyright Notice

Bookshelf ID: NBK37345

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                    - Cite this Page Kane RL, Johnson PE, Town RJ, et al. Economic Incentives for Preventive Care. Rockville (MD): Agency for Healthcare Research and Quality (US); 2004 Aug. (Evidence Reports/Technology Assessments, No. 101.)

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