Although financial incentives are considered an important element in strategies to change prescribing patterns , limited evidence of their effects can be found .
BACKGROUND The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories .
Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care .
Financial incentives seeking to influence prescribers ' behaviour include budgetary arrangements at primary care and hospital setting s ( pharmaceutical budget caps or targets ) , financial rewards for target behaviours or outcomes ( pay for performance interventions ) and reduced benefit margin for prescribers based on medicine sales and prescriptions ( pharmaceutical reimbursement rate reduction policies ) .
This is the first up date of the original version of this review .
OBJECTIVES To determine the effects of pharmaceutical policies using financial incentives to influence prescribers ' practice s on drug use , healthcare utilisation , health outcomes and costs ( expenditures ) .
The extent of the two tier service for fundholders
Abstract Objective : To examine possible differential changes in outpatient referrals to orthopaedic clinics , attendances , and waiting times between  fundholding and non-fundholding general practitioners . Design : Observational controlled study of referrals by general practitioners to orthopaedic out patients between April 1991 and March 1995 . Setting : District health authority in south west Engl and . Subjects : 10 fundholding practice s with 108 300 registered patients ; 22 control practice s with 159 900 registered patients . Main outcome measures : Changes in age st and ardised referral and outpatient attendance ratios for the year before and the two years after achieving fundholder status ; changes in outpatient waiting times . Results : In the year before achieving fundholding status both groups were referring more patients than were being seen . Two years later , referral and attendance ratios had increased by 13 % and 36 % respectively for fundholders and 32 % and 59 % for controls , and both groups were referring fewer patients than were being seen . Attendances represented 112 % of referrals for fundholders and 104 % for controls . In 1991 - 2 , a similar proportion of patients in the two groups was seen within three months of referral . The two hospitals that set up specific clinics exclusively for fundholders showed faster access for patients of fundholders by 1993 - 4 , as did a third hospital without such clinics by 1994 - 5 . Conclusions : Fundholders increased their orthopaedic referrals less than did controls and achieved a better balance between outpatient appointments and referrals . Their patients were likely to be seen more quickly , particularly if the hospital provided special clinics exclusively for fundholders . Lack of case mix information makes it impossible to judge whether these differences benefit or disadvantage patients . Key messages Patients of fundholders had no better access than patients of non-fundholders to orthopaedic services before the practice s became fundholding Fundholders controlled their referrals better than non-fundholders and achieved a better balance between referrals and attendances Fundholders ' patients were more likely to be seen quickly , especially if the receiving hospital laid on specific clinics exclusively for fundholders Information on case mix is needed to identify whether the lower referral rate among fundholders benefits or disadvantages
Although financial incentives are considered an important element in strategies to change prescribing patterns , limited evidence of their effects can be found .
BACKGROUND The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories .
Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care .
Financial incentives seeking to influence prescribers ' behaviour include budgetary arrangements at primary care and hospital setting s ( pharmaceutical budget caps or targets ) , financial rewards for target behaviours or outcomes ( pay for performance interventions ) and reduced benefit margin for prescribers based on medicine sales and prescriptions ( pharmaceutical reimbursement rate reduction policies ) .
This is the first up date of the original version of this review .
OBJECTIVES To determine the effects of pharmaceutical policies using financial incentives to influence prescribers ' practice s on drug use , healthcare utilisation , health outcomes and costs ( expenditures ) .