Financial Incentives for Care Gaps

Study Overview
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Brief Summary
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This project seeks to understand how individuals respond to financial incentive programs for wellness care. In a randomized controlled trial among customers with care gaps, the investigators will experimentally compare the impacts of incentives for gap closure (gift cards), information on existing gaps (mailers), and no intervention. The research objectives are to assess how responsive individuals are to incentives for, and to information about, existing care gaps; and to assess spillovers from incentives onto other care. In addition, impacts on downstream utilization will be studied, which may be impacted if financial incentives are effective at increasing wellness visits.

Detailed Description
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Setting and sample: The study will be conducted among individuals enrolled in an insurance plan offered by an insurance company in the state of Nebraska. The sample will include a subset of individuals eligible for a program designed to improve delivery of care by incentivizing individuals and their dependents to fill care gaps - gaps in recommended care. Interventions: The design will entail two overarching interventions for each incentivized care gap: Incentives, and Information Only. In addition, there will be a control that receives neither. Incentives. Individuals receiving the Incentives intervention for a given care gap will receive a mailer informing them of that gap, and that they are eligible for a gift card if they close that care gap. Information Only. Individuals receiving the Information Only intervention for a given care gap will receive a mailer informing them of that gap, but without information on the incentives available. Control. Individuals receiving the Control intervention for a given care gap will not receive a mailer. All individuals will be made whole following the intervention period, regardless of treatment status; i.e. members will be compensated for closing incentivized care gaps regardless of whether they were informed of their eligibility to do so. The specific Incentivized Care Gaps include: W34, LSC, IMA, CDC Eye Exam and/or CDC Hba1c Screening, CCS, and AWC. Randomization: A separate letter is sent for each care gap, so that individuals may receive more than one letter. The investigators will randomize which letters are sent. The process will be as follows: every individual with a care gap in the sample (a care-gap, beneficiary pair) will be randomly assigned a study status: financial incentive, information only, or no letter. When it comes time to send mailers for each care gap, mailers will be sent according to the intersection of eligibility and care gap-specific treatment assignment. E.g. if at mailing time a participant is eligible for only cervical cancer screening (CCS), that participant will receive the CCS intervention (Control, Information Only, or Incentives) as pre-assigned. If the participant is also eligible for an adolescent well-visit (AWC) incentive based on her dependent's age and visit status, the participant will also receive the AWC intervention as pre-assigned; this intervention may be the same or different from her CCS intervention. Analysis: The investigators will compare the number and rate of care-gap closure at 6 and 18 months following the initial mailing. The investigators will also conduct heterogeneity analysis according to baseline characteristics of the population.

Official Title
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Financial Incentives for Care Gaps: A Randomized Controlled Trial

Conditions
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Delivery of Health Care

Intervention / Treatment
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* Behavioral: Financial Incentives
* Behavioral: Information


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Is a partner organization member in the region of study Has a care gap in one of the six target areas Exclusion Criteria: Participating in another select high-intensity wellness intervention provided by the partner organization

Ages Eligible for Study
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Minimum Age: 21 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Prevention
Allocation: Randomized
Intervention Model: Factorial Assignment
Masking: Single


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| No Intervention: Control: W34<br>Members receiving the Control intervention for the W34 (3- to 6-year-old well visit) gap will not receive a mailer. | |
| Experimental: Information only: W34<br>Members receiving the Information Only intervention for the W34 care gap will receive a mailer informing them of that gap, but not of financial incentives for closing the care gap. | Behavioral: Information<br>* Information on care gap and closure process.<br>|
| Experimental: Incentives: W34<br>Informational W34 mailer and incentive to close gap | Behavioral: Financial Incentives<br>* Incentives for gap closure.<br>Behavioral: Information<br>* Information on care gap and closure process.<br>|
| No Intervention: Control: LSC<br>Members receiving the Control intervention for the LSC (lead screening in children) gap will not receive a mailer. | |
| Experimental: Information only: LSC<br>Informational LSC mailer and incentive to close gap | Behavioral: Information<br>* Information on care gap and closure process.<br>|
| Experimental: Incentives: LSC<br>Members receiving the Incentives intervention for the LSC care gap will receive a mailer informing them of the gap and eligibility for a gift card if they close the gap. | Behavioral: Financial Incentives<br>* Incentives for gap closure.<br>Behavioral: Information<br>* Information on care gap and closure process.<br>|
| No Intervention: Control: IMA<br>No mailer for IMA (immunizations) gap | |
| Experimental: Information only: IMA<br>Informational IMA mailer | Behavioral: Information<br>* Information on care gap and closure process.<br>|
| Experimental: Incentives: IMA<br>Informational IMA mailer and incentive | Behavioral: Financial Incentives<br>* Incentives for gap closure.<br>Behavioral: Information<br>* Information on care gap and closure process.<br>|
| No Intervention: Control: CDC<br>No mailer for CDC (clinical diabetes care) gap | |
| Experimental: Information only: CDC<br>Informational CDC mailer | Behavioral: Information<br>* Information on care gap and closure process.<br>|
| Experimental: Incentives: CDC<br>Informational CDC mailer and incentive | Behavioral: Financial Incentives<br>* Incentives for gap closure.<br>Behavioral: Information<br>* Information on care gap and closure process.<br>|
| No Intervention: Control: CCS<br>No mailer for CCS (cervical cancer screening) | |
| Experimental: Information only: CCS<br>Informational CCS mailer | Behavioral: Information<br>* Information on care gap and closure process.<br>|
| Experimental: Incentives: CCS<br>Informational CCS mailer and incentive | Behavioral: Financial Incentives<br>* Incentives for gap closure.<br>Behavioral: Information<br>* Information on care gap and closure process.<br>|
| No Intervention: Control: AWC<br>No mailer for AWC (adolescent well-care visit) gap | |
| Experimental: Information only: AWC<br>Informational AWC mailer | Behavioral: Information<br>* Information on care gap and closure process.<br>|
| Experimental: Incentives: AWC<br>Informational AWC mailer and incentive | Behavioral: Financial Incentives<br>* Incentives for gap closure.<br>Behavioral: Information<br>* Information on care gap and closure process.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Proportion of care gaps closed | Care gap closure for all care gaps. A care gap is considered closed for an individual or dependent who had not received recommended care (i.e. who had a care gap) at the time of enrollment at the time they receive the recommended care. For example, if a dependent child has not received lead screening (LSC) at the time of enrollment, the LSC care gap is considered closed once the child receives a lead screening. | 6 months, from the date of randomization until end-of-year (i.e., December 31, 2018) | 
| Proportion of care gaps closed | Care gap closure for all care gaps. A care gap is considered closed for an individual or dependent who had not received recommended care (i.e. who had a care gap) at the time of enrollment at the time they receive the recommended care. For example, if a dependent child has not received lead screening (LSC) at the time of enrollment, the LSC care gap is considered closed once the child receives a lead screening. | 18 months, from the date of randomization until December 31, 2019 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Health care expenditure during study - Total claims | (dollars) | 6 months, from the date of randomization until end-of-year | 
| Health care expenditure following study - Total claims | Total claims (dollars) | 12 months, from December 31 2018 - December 31 2019 | 
| Outpatient visits during study | Number of outpatient visits | 6 months, from the date of randomization until end-of-year | 
| Outpatient visits following study | Number of outpatient visits | 12 months, from December 31 2018 - December 31 2019 | 
| Inpatient visits during study | Number of inpatient visits | 6 months, from the date of randomization until end-of-year | 
| Inpatient visits following study | Number of inpatient visits | 12 months, from December 31 2018 - December 31 2019 | 
| Prescriptions during study | Number of prescriptions | 6 months, from the date of randomization until end-of-year | 
| Prescriptions following study | Number of prescriptions | 12 months, from December 31 2018 - December 31 2019 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Professional Practice Gaps