Recorded quality of primary care for patients with diabetes in England before and after the introduction of a financial incentive scheme: a longitudinal observational study Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol Incentive payments to general practitioners aimed at increasing opportunistic testing of young women for chlamydia: a pilot cluster randomised controlled trial Family doctor responses to changes in incentives for influenza immunization under the U.K. Quality and Outcomes Framework pay-for-performance scheme. Changes in Patient Experiences of Primary Care During Health Service Reforms in England Between 2003 and 2007 Effect on maternal and child health services in Rwanda of payment to primary health-care providers for performance: an impact evaluation The Cessation in Pregnancy Incentives Trial (CPIT): study protocol for a randomized controlled trial Healthcare providers’ views on the acceptability of financial incentives for breastfeeding: a qualitative study The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. The effect of introducing a financial incentive to promote application of fluoride varnish in dental practice in Scotland: a natural experiment Effects of individual physician-level and practice-level financial incentives on hypertension care: a randomized trial. Organizational and market influences on physician performance on patient experience measures. How to build and evaluate an integrated health care system for chronic patients: study design of a clustered randomised controlled trial in rural China Using Provider Performance Incentives to Increase HIV Testing and Counseling Services in Rwanda Trust in insurers and access to physicians: associated enrollee behaviors and changes over time. A systematic review of the use of financial incentives and penalties to encourage uptake of healthy behaviors: protocol The Use of Physician Financial Incentives and Feedback to Improve Pediatric Preventive Care in Medicaid Managed Care Copd Performance Indicators In An Integrated Care Program And Its Impact On Health Outcomes: The Recode Cluster Randomized Trial. Randomized trial of four financial-incentive programs for smoking cessation. Financial incentives to improve adherence to antipsychotic maintenance medication in non-adherent patients: a cluster randomised controlled trial. Are financial incentives cost-effective to support smoking cessation during pregnancy? An RCT protocol of varying financial incentive amounts for smoking cessation among pregnant women Prepayment with office-based physicians in publicly funded programs: results from the Children's Medicaid Program.
Background The UK 's Quality and Outcomes Framework ( QOF ) was introduced in 2004/5 , linking remuneration for general practice s to recorded quality of care for chronic conditions , including diabetes mellitus . We assessed the effect of the incentives on recorded quality of care for diabetes patients and its variation by patient and practice characteristics . Methods Using the General Practice Research Data base we selected a stratified sample of 148 English general practice s in Engl and , contributing data from 2000/1 to 2006/7 , and obtained a r and om sample of 653 500 patients in which 23 920 diabetes patients identified . We quantified annually recorded quality of care at the patient-level , as measured by the 17  QOF diabetes indicators , in a composite score and analysed it longitudinally using an Interrupted Time Series design . Results Recorded quality of care improved for all subgroups in the pre-incentive period . In the first year of the incentives , composite quality improved over- and -above this pre-incentive trend by 14.2 % ( 13.7–14.6 % ) . By the third year the improvement above trend was smaller , but still statistically significant , at 7.3 % ( 6.7–8.0 % ) . After 3 years of the incentives , recorded levels of care varied significantly for patient gender , age , years of previous care , number of co-morbid conditions and practice diabetes prevalence . Conclusions The introduction of financial incentives was associated with improvements in the recorded quality of diabetes care in the first year . These improvements included some measures of disease control , but most captured only documentation of recommended aspects of clinical assessment , not patient management or outcomes of care . Improvements in subsequent years were more modest . Variation in care between population groups diminished under the incentives , but remained substantial in some cases Background Despite compelling evidence of the benefits of treatment and well-accepted guidelines for treatment , hypertension is controlled in less than one-half of United States citizens . Methods / design This r and omized controlled trial tests whether explicit financial incentives promote the translation of guideline -recommended care for hypertension into clinical practice and improve blood pressure ( BP ) control in the primary care setting . Using constrained r and omization , we assigned 12 Veterans Affairs hospital outpatient clinics to four study arms : physician-level incentive ; group-level incentive ; combination of physician and group incentives ; and no incentives ( control ) . All participants at the hospital ( cluster ) were assigned to the same study arm . We enrolled 83 full-time primary care physicians and 42 non-physician personnel . The intervention consisted of an educational session about guideline -recommended care for hypertension , five audit and feedback reports , and five disbursements of incentive payments . Incentive payments rewarded participants for chart-documented use of guideline -recommended antihypertensive medications , BP control , and appropriate responses to uncontrolled BP during a prior four-month performance period over the 20-month intervention . To identify potential unintended consequences of the incentives , the study team interviewed study participants , as well as non-participant primary care personnel and leadership at study sites . Chart review s included data collection on quality measures not related to hypertension . To evaluate the persistence of the effect of the incentives , the study design includes a washout period . Discussion We briefly describe the rationale for the interventions being studied , as well as the major design choices . Rigorous research design s such as the one described here are necessary to determine whether performance-based payment arrangements such as financial incentives result in meaningful quality improvements . Trial Registration http://www . clinical 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 r and omized 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 Zeal and Clinical Trial Registry ACTRN12608000499381 OBJECTIVE To analyze the effect of setting higher targets , in a primary care pay-for-performance scheme , on rates of influenza immunization and exception reporting . STUDY SETTING The U.K. Quality and Outcomes Framework links financial rewards for family practice s to four separate influenza immunization rates for patients with coronary heart disease ( CHD ) , chronic obstructive pulmonary disease , diabetes , and stroke . There is no additional payment for immunization rates above an upper threshold . Patients for whom immunization would be inappropriate can be excepted from the practice for the calculation of the practice immunization rate . DATA Practice -level  information on immunizations and exceptions extracted from electronic records of all practice s in Engl and 2004/05 to 2009/10 ( n=8,212 - 8,403 ) . STUDY DESIGN Longitudinal r and om effect multilevel linear regressions comparing changes in practice immunization and exception rates for the four chronic conditions before and after the increase in the upper threshold immunization rate for CHD patients in 2006/07 . PRINCIPAL FINDINGS The 5 percent increase in the upper payment threshold for CHD was associated with increases in the proportion of immunized CHD patients ( 0.41 percent , CI : 0.25 - 0.56 percent ) , and exception was reported ( 0.26 percent , CI : 0.12 - 0.40 percent ) . CONCLUSIONS Making quality targets more dem and ing can not only lead to improvement in quality of care but can also have other consequences PURPOSE Major primary care reforms have been introduced in recent years in the United Kingdom , including financial incentives to improve clinical quality and provide more rapid access to care . Little is known about the impact of these changes on patient experience . We examine patient reports of quality of care between 2003 and 2007 , including r and om sample s of patients on practice lists and patients with long-term conditions . METHODS We conducted a cross-sectional design study of family practice s in which  question naires were sent to serial sample s of patients in 42 representative general practice s in Engl and . Question naires sent to sample s of patients with chronic disease ( asthma , angina , and diabetes ) and r and om sample s of adult patients ( excluding patients who reported any long-term condition ) in 2003 , 2005 , and 2007 addressed issues of access , communication , continuity of care , coordination , nursing care , and overall satisfaction . RESULTS There were no significant changes in quality of care reported by either group of patients between 2003 and 2007 for communication , nursing care , coordination , and overall satisfaction . Some aspects of access improved significantly for patients with chronic disease , but not for the r and om sample s of patients . Patients in both sample s reported seeing their usual physician less often and gave lower satisfaction ratings for continuity of care . Most scores were significantly higher for the chronic illness sample s than for the r and om sample s of patients in 2003 , even after adjusting for age . CONCLUSIONS There was a modest improvement in access to care for patients with chronic illness , but all patients now find it somewhat harder to obtain continuity of care . This outcome may be related to the incentives to provide rapid appointments or to the increased number of specialized clinics in primary care . The possibility of unintended effects needs to be considered when introducing pay for performance schemes BACKGROUND Evidence about the best methods with which to accelerate progress towards achieving the Millennium Development Goals is urgently needed . We assessed the effect of performance-based payment of health-care providers ( payment for performance ; P4P ) on use and quality of child and maternal care services in health-care facilities in Rw and a. METHODS 166 facilities were r and omly assigned at the district level either to begin P4P funding between June , 2006 , and October , 2006 ( intervention group ; n=80 ) , or to continue with the traditional input-based funding until 23 months after study baseline ( control group ; n=86 ) . R and omisation was done by coin toss . We surveyed facilities and 2158 households at baseline and after 23 months . The main outcome measures were prenatal care visits and institutional deliveries , quality of prenatal care , and child preventive care visits and immunisation . We isolated the incentive effect from the re source effect by increasing comparison facilities ' input-based budgets by the average P4P payments made to the treatment facilities . We estimated a multivariate regression specification of the difference-in-difference model in which an individual 's outcome is regressed against a dummy variable , indicating whether the facility received P4P that year , a facility-fixed effect , a year indicator , and a series of individual and household characteristics . FINDINGS Our model estimated that facilities in the intervention group had a 23 % increase in the number of institutional deliveries and increases in the number of preventive care visits by children aged 23 months or younger ( 56 % ) and aged between 24 months and 59 months ( 132 % ) . No improvements were seen in the number of women completing four prenatal care visits or of children receiving full immunisation schedules . We also estimate an increase of 0·157 st and ard deviations ( 95 % CI 0·026 - 0·289 ) in prenatal quality as measured by compliance with Rw and an prenatal care clinical practice guidelines . INTERPRETATION The P4P scheme in Rw and a had the greatest effect on those services that had the highest payment rates and needed the least effort from the service provider . P4P financial performance incentives can improve both the use and quality of maternal and child health services , and could be a useful intervention to accelerate progress towards Millennium Development Goals for maternal and child health . FUNDING World Bank 's Bank-Netherl and s Partnership Program and Spanish Impact Evaluation Fund , the British Economic and Social Research Council , Government of Rw and a , and Global Development Network Background Seventy percent of women in Scotl and have at least one baby , making pregnancy an opportunity to help most young women quit smoking before their own health is irreparably compromised . By quitting during pregnancy their infants will be protected from miscarriage and still birth as well as low birth weight , asthma , attention deficit disorder and adult cardiovascular disease . In the UK , the NICE guidelines : ‘ How to stop smoking in pregnancy and following childbirth ’ ( June 2010 ) highlighted that little evidence exists in the literature to confirm the efficacy of financial incentives to help pregnant smokers to quit . Its first research recommendation was to determine : Within a UK context , are incentives an acceptable , effective and cost-effective way to help pregnant women who smoke to quit ? Design and methods This study is a phase II exploratory individually r and omized controlled trial comparing st and ard care for pregnant smokers with st and ard care plus the additional offer of financial voucher incentives to engage with specialist cessation services and /or to quit smoking during pregnancy .  Participants ( n = 600 ) will be pregnant smokers identified at maternity booking who , when contacted by specialist cessation services , agree to having their details passed to the NHS Smokefree Pregnancy Study Helpline to discuss the trial . The NHS Smokefree Pregnancy Study Helpline will be responsible for telephone consent and follow-up in late pregnancy . The primary outcome will be self reported smoking in late pregnancy verified by cotinine measurement . An economic evaluation will refine cost data collection and assess potential cost-effectiveness while qualitative research interviews with clients and health professionals will assess the level of acceptance of this form of incentive payment . The research questions are : What is the likely therapeutic efficacy ? Are incentives potentially cost-effective ? Is individual r and omization an efficient trial design without introducing outcome bias ? Can incentives be introduced in a way that is feasible and acceptable ? Discussion This phase II trial will establish a workable design to reduce the risks associated with a future definitive phase III multicenter r and omized controlled trial and establish a framework to assess the costs and benefits of financial incentives to help pregnant smokers to quit . Trial registration Current Controlled Trials IS RCT Background Despite a gradual increase in breastfeeding rates , overall in the UK there are wide variations , with a trend towards breastfeeding rates at 6–8 weeks remaining below 40 % in less affluent areas . While financial incentives have been used with varying success to encourage positive health related behaviour change , there is little research on their use in encouraging breastfeeding . In this paper , we report on healthcare providers ’ views around whether using financial incentives in areas with low breastfeeding rates would be acceptable in principle . This research was part of a larger project looking at the development and feasibility testing of a financial incentive scheme for breastfeeding in preparation for a cluster r and omised controlled trial . Methods Fifty – three healthcare providers were interviewed about their views on financial incentives for breastfeeding . Participants were purposively sample d to include a wide range of experience and roles associated with supporting mothers with infant feeding . Semi-structured individual and group interviews were conducted . Data were analysed thematically drawing on the principles of Framework Analysis . Results The key theme emerging from healthcare providers ’ views on the acceptability of financial incentives for breastfeeding  was their possible impact on ‘ facilitating or impeding relationships ’ . Within this theme several additional aspects were discussed : the mother ’s relationship with her healthcare provider and services , with her baby and her family , and with the wider community . In addition , a key priority for healthcare providers was that an incentive scheme should not impact negatively on their professional integrity and responsibility towards women . Conclusion Healthcare providers believe that financial incentives could have both positive and negative impacts on a  mother ’s relationship with her family , baby and healthcare provider . When design ing a financial incentive scheme we must take care to minimise the potential negative impacts that have been highlighted , while at the same time recognising the potential positive impacts for women in areas where breastfeeding rates are low BACKGROUND This study tested the effects of two organizational support processes , the provision of financial incentives for superior clinical performance and the availability of a  patient ( smoker ) registry and proactive telephone support system for smoking cessation , on provider adherence to accepted practice guidelines and associated patient outcomes . METHODS Forty clinics of a large multispecialty medical group practice providing primary care services were r and omly allocated to study conditions . Fifteen clinics each were assigned to the experimental conditions " control " ( distribution of printed versions of smoking cessation guidelines ) and " incentive " ( financial incentive pay-out for reaching preset clinical performance targets ) .  Ten clinics were r and omized to receive financial incentives combined with access to a central ized patient registry and intervention system ( " registry " ) . Main outcome measures were adherence to smoking cessation clinical practice guidelines and patients ' smoking cessation behaviors . RESULTS  Patients ' tobacco use status  was statistically significant ( P < 0.01 ) more frequently identified in clinics with the opportunity for incentives and access to a registry than in clinics in the control condition . Patients visiting registry clinics accessed counseling programs statistically significantly more often ( P < 0.001 ) than patients receiving care in the control condition . Other endpoints did not statistically significantly differ between the experimental conditions . CONCLUSIONS The impact of financial incentives and a patient registry/intervention system in improving smoking cessation clinical practice s and patient behaviors was mixed . Additional research is needed to identify conditions under which such organizational support processes result in significant health care quality improvement and warrant the investment Background Financial incentives are often used to influence professional practice , yet the factors which influence their effectiveness and their behavioural mechanisms are not fully understood . In keeping with clinical guidelines , Childsmile ( Scotl and ’s oral health improvement programme ) advocates twice yearly fluoride varnish application ( FVA ) for children in dental practice . To support implementation Childsmile offered dental practitioners a fee-per-item payment for varnishing 2–5-year-olds ’ teeth through a pilot . In October 2011 payment was extended to all dental practitioners . This paper compares FVA pre- and post-roll-out and explores the financial incentive ’s behavioural mechanisms . Methods A natural experimental approach using a longitudinal cohort of dental practitioners ( n = 1090 ) compared FVA pre- ( time 1 ) and post- ( time 2 ) financial incentive . Responses from practitioners who did not work in a Childsmile pilot practice when considering their 2–5-year-old patients ( novel incentive group )  were compared with all other responses ( continuous incentive group ) . The Theoretical Domains Framework ( TDF ) was used to measure change in behavioural mechanisms associated with the incentive . Analysis of covariance was used to investigate FVA rates and associated behavioural mechanisms in the two groups . Results At time 2 , 709 74 % , of eligible responders , were followed up . In general , FVA rates increased over time for both groups ; however , the novel incentive group experienced a greater increase ( β [ 95 % CI ] = 0.82 [ 0.72 to 0.92 ] ) than the continuous incentive group . Despite this , only 33 % of practitioners reported ‘ always ’ varnishing increased risk 2–5-year-olds ’ teeth following introduction of the financial incentive , 19 % for st and ard risk children . Domain scores at time 2 ( adjusting for time 1 ) increased more for the novel incentive group ( compared to the continuous incentive group ) for five domains : knowledge , social/professional role and identity , beliefs about consequences , social influences and emotion . Conclusions In this large , prospect i ve , population -wide study , a financial incentive moderately increased FVA in dental practice . Novel longitudinal use of a vali date d theoretical framework to underst and behavioural mechanisms suggested that financial incentives operate through complex inter-linked belief systems . While financial incentives are useful in narrowing the gap between clinical guidelines and FVA , multiple intervention approaches are required IMPORTANCE Pay for performance is intended to align incentives to promote high- quality care , but results have been contradictory . OBJECTIVE To test the effect of explicit financial incentives to reward guideline -recommended hypertension care . DESIGN , SETTING , AND PARTICIPANTS Cluster r and omized trial of 12 Veterans Affairs outpatient clinics with 5 performance periods and a 12-month washout that enrolled 83 primary care physicians and 42 nonphysician personnel ( eg , nurses , pharmacists ) . INTERVENTIONS Physician-level ( individual ) incentives , practice -level incentives , both , or none . Intervention participants received up to 5 payments every 4 months ; all participants could access feedback reports . MAIN OUTCOMES AND MEASURES Among a r and om sample , number of patients achieving guideline -recommended blood pressure thresholds or receiving an appropriate response to uncontrolled blood pressure , number of patients prescribed guideline -recommended medications , and number who developed hypotension . RESULTS Mean ( SD ) total payments over the study were $ 4270 ( $ 459 ) , $ 2672 ( $ 153 ) , and $ 1648 ( $ 248 ) for the combined , individual , and practice -level interventions , respectively . The unadjusted baseline and final percentages and the adjusted absolute change over the study in patients meeting the combined blood pressure/appropriate response measure were 75 % to 84 % and 8.84 % ( 95 % CI , 4.20 % to 11.80 % ) for the individual group , 80 % to 85 % and 3.70 % ( 95 % CI , 0.24 % to 7.68 % ) for the practice -level group , 79 % to 88 % and 5.54 % ( 95 % CI , 1.92 % to 9.52 % ) for the combined group , and 86 % to 86 % and 0.47 % ( 95 % CI , -3.12 % to 4.04 % ) for the control group . The adjusted absolute estimated difference in the change between the proportion of patients with blood pressure control/appropriate response for individual incentive and control groups was 8.36 % ( 95 % CI , 2.40 % to 13.00 % ; P=.005 ) . The other incentive groups did not show a significant change compared with controls for this outcome . For medications , the unadjusted baseline and final percentages and the adjusted absolute change were 61 % to 73 % and 9.07 % ( 95 % CI , 4.52 % to 13.44 % ) , 56 % to 65 % and 4.98 % ( 95 % CI , 0.64 % to 10.08 % ) , 65 % to 80 % and 7.26 % ( 95 % CI , 2.92 % to 12.48 % ) , and 63 % to 72 % and 4.35 % ( 95 % CI , -0.28 % to 9.28 % ) , respectively . These changes in the use of guideline -recommended medications were not significant in any of the incentive groups compared with controls , nor was the incidence of hypotension . The effect of the incentive was not sustained after a washout . CONCLUSIONS AND RELEVANCE Individual financial incentives , but not practice -level or combined incentives , result ed in greater blood pressure control or appropriate response to uncontrolled blood pressure ; none of the incentives result ed in greater use of guideline -recommended medications or increased incidence of hypotension compared with controls . Further research is needed on the factors that contributed to these findings . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00302718 OBJECTIVE To examine the extent to which medical group and market factors are related to individual primary care physician ( PCP ) performance on patient experience measures . DATA SOURCES This study employs  Clinician and Group CAHPS survey data ( n=105,663 ) from 2,099 adult PCPs belonging to 34 diverse medical groups across California . Medical group directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the adoption of patient experience improvement strategies . Primary care services area ( PCSA ) data were used to characterize the market environment of physician practice s. STUDY DESIGN We used multilevel models to estimate the relationship between medical group and market factors and physician performance on each Clinician and Group CAHPS measure . Models statistically controlled for respondent characteristics and accounted for the clustering of respondents within physicians , physicians within medical groups , and medical groups within PCSAs using r and om effects . PRINCIPAL FINDINGS Compared with physicians belonging to independent practice associations , physicians belonging to integrated medical groups had better performance on the communication ( p=.007 ) and care coordination ( p=.03 ) measures . Physicians belonging to medical groups with greater numbers of PCPs had better performance on all measures . The use of patient experience improvement strategies was not associated with performance . Greater emphasis on productivity and efficiency criteria in individual physician financial incentive formulae was associated with worse access to care ( p=.04 ) . Physicians located in PCSAs with higher area-level deprivation had worse performance on the access to care ( p=.04 ) and care coordination ( p<.001 ) measures . CONCLUSIONS Physicians from integrated medical groups and groups with greater numbers of PCPs performed better on several patient experience measures , suggesting that organized care processes adopted by these groups may enhance patients ' experiences . Physicians practicing in markets with high concentrations of vulnerable population s may be disadvantaged by constraints that affect performance . Future studies should clarify the extent to which performance deficits associated with area-level deprivation are modifiable Background While integrated health care system has been proved an effective way to help improving patient health and system efficiency , the exact behaviour model and motivation approach are not so clear in poor rural areas where health human re sources and continuous service provision are urgently needed . To gather solid evidence , we initiated a comprehensive intervention project in Qianjiang District , southwest part of rural China in 2012 . And after one-year 's pilot , we developed an intervention package of team service , comprehensive pathway and prospect ive- and performance-based payment system . Methods To testify the potential influence of payment interventions , we use clustered r and omised controlled trial , 60 clusters are grouped into two treatment groups and one control group to compare the time and group differences . Difference-in-differences model and structural equation modelling will be used to analyse the intervention effects and pathway . The outcomes are : quality of care , disease burden , supplier cooperative behaviour and patient utilisation behaviour and system efficiency . Repeated multivariate variance analysis will be used to statistically examine the outcome differences . Discussion This is the first trial of its kind to prove the effects and efficiency of integrated care . Though we adopted r and omised controlled trial to gather the highest rank of evidence , still the fully r and omisation was hard to realise in health policy reform experiment . To compensate , the design er should take efforts on control for the potential confounders as much as possible . With this trial , we assume the effects will come from : ( 1 ) improvement on the quality of life through risk factors control and lifestyles change on patient 's behaviours ; ( 2 ) improvement on quality of care through continuous care and coordinated supplier behaviours ; ( 3 ) improvement on the system efficiency through active interaction between suppliers and patients . Conclusion The integrated care system needs collaborative work from different levels of caregivers . So it is extremely important to consider the supplier cooperative behaviour . In this trial , we introduced payment system to help the delivery system integration through providing financial incentives to motivate people to play their roles . Also , the multidisciplinary team , the multi-institutional pathway and system global budget and pay-for-performance payment system could afford as a solution Paying for performance provides financial rewards to medical care providers for improvements in performance measured by specific utilization and quality of care indicators . In 2006 , Rw and a began a paying for performance scheme to improve health services delivery , including HIV/AIDS services . This study examines the scheme 's impact on individual and couples HIV testing and counseling and using data from a prospect i ve quasi-experimental design . The study finds a positive impact of paying for  performance  with an increase of 6.1 percentage points in the probability of individuals having ever been tested . This positive impact is stronger for married individuals : 10.2 percentage points . The results also indicate larger impacts of paying for performance on the likelihood that the respondent reports both partners have ever been tested , especially among discordant couples ( 14.7 percentage point increase ) in which only one of the partners is HIV positive OBJECTIVE Most studies of trust in the medical arena have focused on trust in physicians rather than trust in health insurers , and have been cross-sectional rather than longitudinal studies . This study examined associations among trust in a managed care insurer , trust in one 's primary physician , and subsequent enrollee behaviors relating to source of care . The study also documents changes in trust in the study population following the disclosure of physician incentives . STUDY SETTING A medium-sized ( 300,000 member ) HMO , located in the southeastern United States . DATA COLLECTION One to two years after baseline , we r and omly resurveyed a quarter ( n = 558 ) of the initial study population of a large intervention study design ed to measure the impact of disclosing HMO financial incentives on patient trust . This follow-up study was also design ed to measure the effects of trust on source of care . ANALYSES Multivariate regression analyses of survey data examined associations between baseline levels of trust and subsequent enrollee behaviors such as using a non-PCP physician without a PCP referral , as well as changes in trust since baseline . RESULTS High baseline insurer trust was associated with a lower probability of a patient seeking care from a non-PCP physician ( OR = 0.55 , 95 percent CI : 0.33 , 0.91 ) . No long-term effects of prior disclosure of financial incentives were observed . Overall , there was a slight increase in overall trust in the insurer ( 1.8 percent , p < .05 ) but no change in trust in one 's primary physician . The increase in insurer trust was primarily restricted to 23 percent of the enrollees who had changed their PCPs following the baseline survey ( 6.6 percent , p < .01 ) . In multivariate analyses , changing physicians was the most significant predictor of increased insurer trust ( OR = 2.17 , 95 percent CI : 1.37 , 3.43 ) . CONCLUSIONS . Trust in one 's insurer seems to change over time more than trust in one 's primary physician , and is predictive of enrollee behaviors such as seeking care from other physicians . The ability to change physicians seems to increase trust in the insurer Background The use of financial incentives and penalties to encourage uptake of healthy behaviors is increasingly seen as a viable intervention in developed countries . Previous review s of the effectiveness of financial incentives and penalties for encouraging the uptake of healthy behaviors have focused on individual behaviors making it difficult to draw overall conclusions about the effectiveness of such interventions . This systematic review will explore the effectiveness of financial incentives and penalties for encouraging a wide range of behaviors , including : smoking cessation , increased physical activity , healthier dietary intake , sensible patterns of alcohol consumption , safe sun , safe sex , and primary preventive clinical behaviors . Methods Systematic methods will be used to search existing literature and screen studies for inclusion . All studies that meet the following inclusion criteria will be included in the review : participants were 18 years old or older and living in high-income countries ; interventions included cash or cash-like incentives to promote the uptake of healthy behaviors , or cash or cash-like penalties to discourage unhealthy behaviors ; the comparator was usual care or no intervention ; study design was r and omized controlled trial , cluster r and omized controlled trial , controlled before and after study , or interrupted time series analysis . Two review ers will independently screen the publications to ensure they meet the inclusion criteria . Quality will be assessed by two research ers , working independently , using the Cochrane risk of bias tool . Meta- analysis will be conducted , if appropriate . Any studies identified as at ‘ high risk of bias ’ will be excluded from meta- analysis . Discussion This systematic review will provide policy-relevant recommendations for the use of financial incentives and penalties as a method of encouraging uptake of healthy behaviors Objective . Immunizations and other cost-effective preventive services remain underused by many children , especially those living in poverty . Given the effectiveness of provider-based tracking systems and the widespread use by managed care organizations of financial incentives to influence physician practice patterns , we design ed and tested an intervention combining these strategies . We studied whether a system of semiannual assessment and feedback , coupled with financial incentives , could improve pediatric preventive care in a Medicaid health maintenance organization ( HMO ) . Methodology . We r and omly assigned primary care sites serving children in a Medicaid HMO to one of three groups : a feedback group ( where physicians received written feedback about compliance scores ) , a feedback and incentive group ( where physicians received feedback and a financial bonus when compliance criteria were met ) , and a control group . We evaluated compliance with pediatric preventive care guidelines  through semiannual chart audits during the years 1993 to 1995 . Results . Compliance with pediatric preventive care improved dramatically in the study period . Repeated measures ANOVA demonstrated a significant increase in all three study groups throughout the time in total compliance scores ( from 56%–73 % ) , as well as scores for immunizations ( from 62%–79 % ) and other preventive care ( from 54%–71 % ) . However , no significant differences were observed between either intervention group and the control group , nor were there any interaction ( group-by-time ) effects . Conclusions . Feedback to physicians , with or without financial incentives , did not improve pediatric preventive care in this Medicaid HMO during a time of rapid , secular improvements in care . Possible explanations include the context and timing of the intervention , the magnitude of the financial incentives , and lack of physician awareness of the intervention Objectives : Similar to many European countries , performance-based financial incentives are introduced in the Netherl and s to facilitate the implementation of integrated care programs . The aim of these programs is to enhance patients ’ health by improving quality of care . Performance indicators are used to measure quality of care and reward healthcare providers . However , the real benefit to patients remains largely uncertain . This study investigate ( I ) if implementation of an integrated care program improves performance indicators and ( II ) the impact performance indicators on health outcomes . Methods : This is a sub- study of the RECODE cluster r and omised controlled trial , the largest clinical trial of an integrated care program for Chronic Obstructive Pulmonary Disease ( COPD ) patients in primary care to date . From 38 Dutch GPs , we collected three-year prospect i ve data on performance indicators ( mostly process indicators ) and health outcomes ( smoking status , level of physical activity , health-related quality -of-life ( HRQoL ) ) of 913 COPD patients . Multilevel repeated measurement models were used to assess the impact of integrated care on performance indicators and the impact of performance indicators on health outcomes . Results : COPD performance indicators improved over time and these improvements were higher in the integrated care group than in the usual care group , indicating improved quality of care . Four indicators ( whether BMI was measured , whether physical activity was checked , whether functional status was monitored , whether a spirometry test was done ) were associated with an immediate improvement ( i.e. in the same year ) in disease-specific HRQoL as measured with the SGRQ . The latter indicator plus ‘ inhalation technique checked ’ also had a delayed impact on HRQol ( i.e. improved HRQoL in the year after the indicator was registered ) . The indicators related to smoking did not affect health outcomes . Conclusions : The integrated care program did improve performance indicators of the quality of care and some of these indicators were predictive of improved BACKGROUND Financial incentives promote many health behaviors , but effective ways to deliver health incentives remain uncertain . METHODS We r and omly assigned CVS Caremark employees and their relatives and friends to one of four incentive programs or to usual care for smoking cessation . Two of the incentive programs  targeted individuals , and two targeted groups of six participants . One of the individual-oriented programs and one of the group-oriented programs entailed rewards of approximately $ 800 for smoking cessation ; the others entailed refundable deposits of $ 150 plus $ 650 in reward payments for successful participants . Usual care included informational re sources and free smoking-cessation aids . RESULTS Overall , 2538 participants were enrolled . Of those assigned to reward-based programs , 90.0 % accepted the assignment , as compared with 13.7 % of those assigned to deposit-based programs ( P<0.001 ) . In intention-to-treat analyses , rates of sustained abstinence from smoking through 6 months were higher with each of the four incentive programs ( range , 9.4 to 16.0 % ) than with usual care ( 6.0 % ) ( P<0.05 for all comparisons ) ; the superiority of reward-based programs was sustained through 12 months . Group-oriented and individual-oriented programs were associated with similar 6-month abstinence rates ( 13.7 % and 12.1 % , respectively ; P=0.29 ) . Reward-based programs were associated with higher abstinence rates than deposit-based programs ( 15.7 % vs. 10.2 % , P<0.001 ) . However , in instrumental-variable analyses that accounted for differential acceptance , the rate of abstinence at 6 months was 13.2 percentage points ( 95 % confidence interval , 3.1 to 22.8 ) higher in the deposit-based programs than in the reward-based programs among the estimated 13.7 % of the participants who would accept participation in either type of program . CONCLUSIONS Reward-based programs were much more commonly accepted than deposit-based programs , leading to higher rates of sustained abstinence from smoking .  Group-oriented incentive programs were no more effective than individual-oriented programs . ( Funded by the National Institutes of Health and CVS Caremark ; Clinical Trials.gov number , NCT01526265 . ) BACKGROUND Poor adherence to long-term antipsychotic injectable ( LAI ) medication in patients with psychotic disorders is associated with a range of negative outcomes . No psychosocial intervention has been found to be consistently effective in improving adherence . OBJECTIVES To test whether or not offering financial incentives is effective and cost-effective in improving adherence and to explore patient and clinician experiences with such incentives . DESIGN A cluster r and omised controlled trial with economic and nested qualitative evaluation . The intervention period lasted for 12 months with 24 months ' follow-up . The unit of r and omisation was mental health teams in the community . SETTING Community teams in secondary mental health care . PARTICIPANTS Patients with a diagnosis of schizophrenia , schizoaffective psychosis or bipolar illness , receiving ≤ 75 % of their prescribed LAI medication . In total , 73 teams with 141 patients ( intervention n = 78 and control n = 63 ) were included . INTERVENTIONS Participants in the intervention group received £ 15 for each LAI medication . Patients in the control group  received treatment as usual . MAIN OUTCOME MEASURES PRIMARY OUTCOME adherence to LAI medication  ( the percentage of received out of those prescribed ) . SECONDARY OUTCOMES percentage of patients with at least 95 % adherence ; clinical global improvement ; subjective quality of life ; satisfaction with medication ; hospitalisation ; adverse events ; and costs . Qualitative evaluation : semistructured interviews with patients in the intervention group and their clinicians . RESULTS PRIMARY OUTCOME outcome data were available for 131 patients .  Baseline adherence was 69 % in the intervention group and 67 % in the control group . During the intervention period , adherence was significantly higher in the intervention group than in the control group ( 85 % vs. 71 % ) [ adjusted mean difference 11.5 % , 95 % confidence interval ( CI ) 3.9 % to 19.0 % ; p = 0.003 ] . Secondary outcome : patients in the intervention group showed statistically significant improvement in adherence of at least 95 % ( adjusted odds ratio 8.21 , 95 % CI 2.00 to 33.67 ; p = 0.003 ) and subjective quality of life ( difference in means 0.71 , 95 % CI 0.26 to 1.15 ; p = 0.002 ) . Follow-ups : after incentives stopped , adherence did not differ significantly between groups , neither during the first 6 months ( adjusted difference in means -7.4 % , 95 % CI -17.0 % to 2.1 % ; p = 0.175 ) nor during the period from month 7 to month 24 ( difference in means -5.7 % , 95 % CI -13.1 % to 1.7 % ; p = 0.130 ) . Cost-effectiveness : the average costs of the financial incentives was £ 303 . Overall costs per patient were somewhat higher in the intervention group , but the difference was not significant . Semistructured interviews : the majority of patients and clinicians reported positive experiences with the incentives beyond their monetary value . These included improvement in the therapeutic relationship . The majority of both patients and clinicians perceived no negative impact after the intervention was stopped after 1 year . CONCLUSIONS Financial incentives are effective in improving adherence to LAI medication . Health-care costs ( including costs of the financial incentive ) are unlikely to be increased substantially by this intervention . Once the incentives stop , the advantage is not maintained . The experiences of both patients and clinicians are largely , but not exclusively , positive . Whether or not financial incentives are effective for patients with more favourable background , those on oral mediation or for shorter or longer time periods remains unknown . TRIAL REGISTRATION Current Controlled Trials IS RCT N77769281 . FUNDING This project was funded by the National Institute for Health Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol . 20 , No. 70 . See the NIHR Journals Library website for further project information AIMS To investigate the cost-effectiveness of up to £ 400 worth of financial incentives for smoking cessation in pregnancy as an adjunct to routine health care . DESIGN Cost-effectiveness analysis based on a Phase II r and omized controlled trial ( RCT ) and a cost-utility analysis using a life-time Markov model . SETTING The RCT was undertaken in Glasgow , Scotl and . The economic analysis was undertaken from the UK National Health Service ( NHS ) perspective . PARTICIPANTS A total of 612 pregnant women r and omized to receive usual cessation support plus or minus financial incentives of up to £ 400 vouchers ( US $ 609 ) , contingent upon smoking cessation . MEASUREMENTS Comparison of usual support and incentive interventions in terms of cotinine-vali date d quitters , quality -adjusted life years ( QALYs ) and direct costs to the NHS . FINDINGS The incremental cost per quitter at 34 - 38 weeks pregnant was £ 1127 ($1716).This is similar to the st and ard look-up value derived from Stapleton & West 's published ICER tables , £ 1390 per quitter , by looking up the Cessation in Pregnancy Incentives Trial ( CIPT ) incremental cost ( £ 157 ) and incremental 6-month quit outcome ( 0.14 ) . The life-time model result ed in an incremental cost of £ 17 [ 95 % confidence interval ( CI ) = -£93 , £ 107 ] and a gain of 0.04 QALYs ( 95 % CI = -0.058 , 0.145 ) , giving an ICER of £ 482/QALY ( $ 734/QALY ) . Probabilistic sensitivity analysis indicates uncertainty in these results , particularly regarding relapse after birth . The expected value of perfect information was £ 30 million ( at a willingness to pay of £ 30 000/QALY ) , so given current uncertainty , additional research is potentially worthwhile . CONCLUSION Financial incentives for smoking cessation in pregnancy are highly cost-effective , with an incremental cost per quality -adjusted life years of £ 482 , which is well below recommended decision thresholds Background Smoking during pregnancy is harmful to the unborn child . Few smoking cessation interventions have been successfully incorporated into st and ard antenatal care . The main aim of this study is to determine the feasibility of a personal financial incentive scheme for encouraging smoking cessation among pregnant women . Design A pilot r and omised control trial will be conducted to assess the feasibility and potential effectiveness of two varying financial incentives that increase incrementally in magnitude ( $ 20 vs. $ 40AUD ) , compared to no incentive in reducing smoking in pregnant women attending an Australian public hospital antenatal clinic . Method Ninety ( 90 ) pregnant women who self-report smoking in the last 7 days and whose smoking status is biochemically verified , will be block r and omised into one of three groups : a. No incentive control group ( n=30 ) , b. $ 20 incremental incentive group ( n=30 ) , and c. $ 40 incremental incentive group ( n=30 ) . Smoking status will be assessed via a self-report computer based survey in nine study sessions with saliva cotinine analysis used as biochemical validation . Women in the two incentive groups will be eligible to receive a cash reward at each of eight measurement points during pregnancy if 7-day smoking cessation is achieved . Cash rewards will increase incrementally for each period of smoking abstinence . Discussion Identifying strategies that are effective in reducing the number of women smoking during pregnancy and are easily adopted into st and ard antenatal practice is of utmost importance . A personal financial incentive scheme is a potential antenatal smoking cessation strategy that warrants further investigation . Trial registration Australian New Zeal and Clinical Trials Registry ( ANZCTR ) number : This paper is a report of the results of a demonstration design ed to provide empirical evidence regarding the effects of alternative approaches to paying physicians for serving children in the Medicaid program : ( 1 ) visit fees set at twice regular Medicaid fees in return for physician agreement to manage utilization and ( 2 ) capitation and financial risk-sharing along with the same physician agreement to manage utilization .  Participating physicians were assigned r and omly to either of the two payment groups . Comparisons of utilization and expenditures were made between these two plans and the regular Medicaid program ( fee-for-service , low fees ) . Results showed no adverse effect of capitation payments on primary care visits to office-based physicians . Capitation physician referrals to specialists decreased relative to all other groups studied , consistent with the theory that the financial incentives in capitation will lead primary care physicians to reduce referrals to specialists
Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures , but not all .
The use of financial incentives to reward PCPs for improving the quality of primary healthcare services is growing .
However , there is insufficient evidence to support or not support the use of financial incentives to improve the quality of primary health care .
BACKGROUND The use of blended payment schemes in primary care , including the use of financial incentives to directly reward ' performance ' and ' quality ' is increasing in a number of countries .
There are many examples in the US , and the Quality and Outcomes Framework ( QoF ) for general practitioners ( GPs ) in the UK is an example of a major system-wide reform .
Despite the popularity of these schemes , there is currently little rigorous evidence of their success in improving the quality of primary health care , or of whether such an approach is cost-effective relative to other ways to improve the quality of care .
OBJECTIVES The aim of this review is to examine the effect of changes in the method and level of payment on the quality of care provided by primary care physicians ( PCPs ) and to identify : i ) the different types of financial incentives that have improved quality ; ii ) the characteristics of patient population s for whom quality of care has been improved by financial incentives ; and iii ) the characteristics of PCPs who have responded to financial incentives .