A systematic review of the use of financial incentives and penalties to encourage uptake of healthy behaviors: protocol The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. Patients as Mercenaries?: The Ethics of Using Financial Incentives in the War on Unhealthy Behaviors An Empirical Evaluation of the Effectiveness of Tangible Incentives in Increasing Participation and Behavior Change in a Worksite Health Promotion Program The effect of introducing a financial incentive to promote application of fluoride varnish in dental practice in Scotland: a natural experiment Can Financial Incentives Help People Trying to Establish New Habits? Experimental Evidence with New Gym Members Coupling Financial Incentives With Direct Mail in Population-Based Practice The use of monetary incentives in a community survey: impact on response rates, data quality, and cost. Using Provider Performance Incentives to Increase HIV Testing and Counseling Services in Rwanda Participation in health promotion programs by the rural elderly. Improving Return Rates for Health-Care Outcome Effect of pay-for-performance incentives on quality of care in small practices with electronic health records: a randomized trial. Design, rationale, and baseline characteristics of a cluster randomized controlled trial of pay for performance for hypertension treatment: study protocol Controlled trial of a time-efficient method of health promotion. The Reinforcing Therapist Performance (RTP) experiment: Study protocol for a cluster randomized trial The Use of Physician Financial Incentives and Feedback to Improve Pediatric Preventive Care in Medicaid Managed Care The effect of physician disclosure of financial incentives on trust.
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 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 Consider the following paradox : few people would balk if research ers offered smokers $ 1,000 to participate in a year-long r and omized trial of a smoking cessation intervention , yet many would find it distasteful for a large employer to pay its smoking employees an extra $ 1,000 if they remained smoke-free for one year . Such discrepant judgments are underst and able from the perspective of classical economics . Research participants merit compensation for the risks and opportunity costs they endure in the service of public health , whereas individuals should need no reward for promoting their own well being . However , contrary to traditional theories of rationality , people frequently fail to make health-promoting choices , particularly when such choices require short-term sacrifices to foster long-term goals .1,2 Thus , corporate and government health plan leaders are increasingly applying extrinsic motivations such as financial incentives and other programs to augment health – particularly cardiovascular health – while hopefully increasing productivity and restraining costs.3 , 4 Early evidence suggests that financial incentives can effectively promote the cardioprotective behaviors of smoking cessation,5 , 6 weight loss,7 , 8 and cholesterol reduction.9  Incentives are also currently being studied as a means of promoting warfarin adherence.10 Although the results of these early studies are promising , further research is needed to determine which incentive structures and amounts are optimal , assess the ability of incentives to produce sustained behavior changes , and evaluate the cost-effectiveness of implementing incentive programs  . Ethical dimensions of the incentives themselves are also in need of further analysis . For example , some have charged that financial incentive programs are coercive , inequitable , and inconsistent with shared social values.11 Others have even suggested that implementing incentive programs serves to punish patients for their illnesses.12 In this essay , we outline the rationale for incentive programs to promote cardiovascular health , identify the ethical arguments that have been used to challenge such programs , and assess the merits of these arguments The first is that they have value in enhancing the program ’s salience . For participants they serve as a reminder of their commitment and goals . For non participants they may function as a means of making them more aware of the program and thus enhancing the likelihood that they will participate in future program offerings . A second reason for using tangible incentives is for their direct motivational value . To the extent that they are delivered contingent on level of participation or accomplishment , employees may participate at a higher level and change their behavior more in order to earn these rewards . A number of worksite health promotion programs have employed tangible incentives . 4 - 1 ° In the well-known Live for Life program developed by Johnson and Johnson , for example , employees are offered annual risk factor screening as well as a variety of educational classes on diet , exercise , smoking cessation , and stress management . Participants in these classes receive a variety of tangible items , including T-shirts , pens , and caps . This program is reported to have had positive effects on smoking , l~ exercise ] 2 and absenteeism ? " 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 We conducted a r and omized controlled trial testing the effect of modest incentives to attend the gym among new members of a fitness facility , a population that is already engaged in trying to change a health behavior . Our experiment r and omized 836 new members of a private gym into a control group , receiving a $ 30 payment unconditionally , or one of 3 incentive groups , receiving a payment if they attended the gym at least 9 times over their first 6 weeks as members . The incentives were a $ 30 payment , a $ 60 payment , and an item costing $ 30 that leveraged the endowment effect . These incentives had only moderate impacts on attendance during members ’ first 6 weeks and no effect on their subsequent visit trajectories . We document substantial overconfidence among new members about their likely visit rates and discuss how overconfidence may undermine the effectiveness of a modest incentive program Financial incentives are being used increasingly to encourage a wide array of health behaviors because of their well-established efficacy . However , little is known about how to translate incentive-based strategies to public health practice geared toward improving population -level health , and a dearth of research exists on how individuals respond to incentives through public health communication strategies such as direct mail . This study reports results of a population -based r and omized controlled trial testing a direct mail , incentive-based intervention for promoting mammography uptake . The study population was composed of a r and om sample of Minnesota women enrolled in Medicare fee-for-service and overdue for breast cancer screening . Participants ( N = 18,939 ) were r and omized into three groups : ( 1 ) Direct Mail only , ( 2 ) Direct Mail plus Incentive , and ( 3 ) Control . Both direct mail groups received two mailers with a message about the importance of mammography ; however , Mail plus Incentive mailers also offered a $ 25 incentive for getting a mammogram . Logistic regression analyses measured intervention effects . Results showed the odds for receiving mammography were significantly higher for the Direct Mail plus Incentive group compared with both Direct Mail only and Control groups . The use of incentives also proved to be cost-effective . Additionally , the Direct Mail only group was more likely to receive mammography than the Control group . Findings offer experimental evidence on how the population -based strategy of direct mail coupled with a financial incentive can encourage healthy behavior , as well as how incentive-based programs can be translated into health promotion practice aim ed at achieving population -level impact OBJECTIVES To assess the effect of incentive size on response rates , data quality , and cost in a digestive health status mail survey of a community sample of health plan enrollees . DATA SOURCES / SETTING The study population was selected from a data base of enrollees in various health plans obligated to receive care at Park Nicollet Clinic-HealthSystem Minnesota , a large , multispecialty group in Minneapolis , Minnesota , and the nearby suburbs . STUDY DESIGN A total of 1,800 HealthSystem Minnesota enrollees were r and omly assigned to receive a survey with an incentive of $ 5 or $ 2 . The response rates for each incentive level were determined . Data quality , as indicated by item nonresponse and scale scores , was measured . Total cost and cost per completed survey were calculated . PRINCIPAL FINDINGS The response rate among enrollees receiving $ 5 ( 74.3 percent ) was significantly higher than among those receiving $ 2 ( 67.4 percent ) ; differences were more pronounced in the first wave of data collection . Data quality did not differ between the two incentive groups . The total cost per completed survey was higher in the $ 5 condition than in the $ 2 condition . CONCLUSIONS A $ 5 incentive result ed in a higher response rate among a community patient sample with one mailing than did a $ 2 incentive . However , the response rates in the $ 2 condition approached the level of the $ 5 incentive , and costs were significantly lower when the full follow-up protocol was completed . Response rates were marginally increased by follow-up phone calls . The incentive level did not influence data quality . The results suggest if a survey budget is limited and a timeline is not critical , a $ 2 incentive provides an affordable means of increasing participation 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 The Health Care Financing Administration ( HCFA ) funded a series of demonstration programs to learn about the implication s of extending coverage for disease prevention/health promotion services to Medicare beneficiaries . This article examines the use of such services by a rural population under this demonstration program . Individuals enrolled in the demonstration were eligible for specific risk reduction interventions . They were enrolled in one of two groups : ( 1 ) a  hospital-based group in which hospitals were paid a capitated fee for providing all services and ( 2 ) a physician-based group in which physicians were paid fee-for-service for providing each service . Chi-square tests of association as well as logistic regression models were used to assess whether eligibility for services , and use of services by those eligible , varied by group and by sociodemographic characteristics . Forty-one percent were eligible for a nutrition program , 11 % for smoking  cessation  , 2 % for alcohol counseling , and 7 % for  dementia/depression evaluations . Participation in the programs varied across the programs and within programs by gender , education , and group assignment . Older rural Americans will use some disease prevention/health promotion services if they are covered by Medicare . Use will be higher among those with more education . Rural beneficiaries are more likely to use preventive services if encouraged to do so by their doctors rather than by hospital-based programs The objective was to test two methods of reducing loss of data in follow-up by abbreviating the question naire and offering a token monetary incentive .  Primary data were collected between September 14 , 1998 and July 23 , 1999 from an adult psychiatric population , representing about 50 % of all patients , all of whom agreed to participate in a quality -assurance monitoring program . Briefer components of the SF-36 Health Status Survey were expected to yield higher return rates than would the SF-36 plus a form assessing amount of treatment received . Small monetary incentives were expected to result in higher return rates also . Patients were r and omly assigned to the groups ( n = 73 each ) . Abbreviation of the question naire and use of a monetary incentive each reduced attrition by 10 % . A diminishing returns effect for both methods was observed . Further study of a possible interaction between the question naire 's length and monetary incentive is recommended IMPORTANCE Most evaluations of pay-for-performance ( P4P ) incentives have focused on large-group practice s. Thus , the effect of P4P in small practice s , where many US residents receive care , is largely unknown . Furthermore , whether electronic health records ( EHRs ) with chronic disease management capabilities support small- practice response to P4P has not been studied . OBJECTIVE To assess the effect of P4P incentives on quality in EHR-enabled small practice s in the context of an established quality improvement initiative . DESIGN , SETTING , AND PARTICIPANTS A cluster-r and omized trial of small ( < 10 clinicians ) primary care clinics in New York City from April 2009 through March 2010 . A city program provided all participating clinics with the same EHR software with decision support and patient registry functionalities and quality improvement specialists offering technical assistance . INTERVENTIONS Incentivized clinics were paid for each patient whose care met the performance criteria , but they received higher payments for patients with comorbidities , who had Medicaid insurance , or who were uninsured ( maximum payments : $ 200/patient ; $ 100,000/clinic ) . Quality reports were given quarterly to both the intervention and control groups . MAIN OUTCOMES AND MEASURES Comparison of differences in performance improvement , from the beginning to the end of the study , between  control  and  intervention  clinics for  aspirin or antithrombotic prescription , blood pressure control , cholesterol control , and smoking cessation interventions .  Mixed-effects logistic regression was used to account for clustering of patients within clinics , with a treatment by time interaction term assessing the statistical significance of the effect of the intervention . RESULTS Participating clinics ( n = 42 for each group ) had similar baseline characteristics , with a mean of 4592 ( median , 2500 ) patients at the intervention group clinics and 3042 ( median , 2000 ) at the control group clinics . Intervention clinics had greater adjusted absolute improvement in rates of appropriate antithrombotic prescription ( 12.0 % vs 6.1 % , difference : 6.0 % [ 95 % CI , 2.2 % to 9.7 % ] , P = .001 for interaction term ) , blood pressure control ( no comorbidities : 9.7 % vs 4.3 % , difference : 5.5 % [ 95 % CI , 1.6 % to 9.3 % ] , P = .01 for interaction term ; with diabetes mellitus : 9.0 % vs 1.2 % , difference : 7.8 % [ 95 % CI , 3.2 % to 12.4 % ] , P = .007 for interaction term ; with diabetes mellitus or ischemic vascular disease : 9.5 % vs 1.7 % , difference : 7.8 % [ 95 % CI , 3.0 % to 12.6 % ] , P = .01 for interaction term ) , and in smoking cessation interventions  ( 12.4 % vs 7.7 % , difference : 4.7 % [ 95 % CI , -0.3 % to 9.6 % ] , P = .02 for interaction term ) . Intervention clinics performed better on all measures for Medicaid and uninsured patients except cholesterol control , but no differences were statistically significant . CONCLUSIONS AND RELEVANCE Among small EHR-enabled clinics , a P4P incentive program compared with usual care result ed in modest improvements in cardiovascular care processes and outcomes . Because most proposed P4P programs are intended to remain in place more than a year , further research is needed to determine whether this effect increases or decreases over time . TRIAL REGISTRATION clinical trials.gov Identifier : NCT00884013 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 Integrating health promotion into daily clinical practice is a challenging undertaking . This project was a prospect i ve trial of a brief physician intervention program , performed as part of routine patient care , that addressed six areas of patients ' lifestyle risks ( nutrition , exercise , alcohol use , smoking , stress , and seat belt use ) . The components of the program were lifestyle assessment , physician prescription of lifestyle change , and educational material s.  Patients visiting a family practice residency model office for any reason were selected to receive all program components  ,  parts of the program , or no program components .  Lifestyle behavior changes over the ensuing four-week period were measured for all groups by a structured phone interview . Patients who received one or more components of the program reported significantly more change at follow-up than those who received no program components ( P = .001 ) ; the greatest change was seen in the group that received all of the program components . Demographic variables that were significantly related to a higher degree of change were female sex , previous contact with the physician , and being married . In this sample age , income , and education were not related to behavior change . Motivation to change -- an expressed desire to work on a given lifestyle area -- was a stronger predictor of change than any demographic variable Background Rewarding provider performance has been recommended by the Institute of Medicine as an approach to improve the quality of treatment , yet little empirical research currently exists that has examined the effectiveness and cost-effectiveness of such approaches . The aim of this study is to test the effectiveness and cost-effectiveness of providing monetary incentives directly to therapists as a method to improve substance abuse treatment service delivery and subsequent client treatment outcomes . Design Using a cluster r and omized design , substance abuse treatment therapists from across 29 sites were assigned by site to either an implementation as usual ( IAU ) or pay-for-performance ( P4P ) condition . Participants Substance abuse treatment therapists participating in a large dissemination and implementation initiative funded by the Center for Substance Abuse Treatment . InterventionTherapists in both conditions received comprehensive training and ongoing monitoring , coaching , and feedback . However , those in the P4P condition also were given the opportunity to earn monetary incentives for achieving two sets of measurable behaviors related to quality implementation of the treatment . Outcomes Effectiveness outcomes will focus on the impact of the monetary incentives to increase the proportion of adolescents who receive a targeted threshold level of treatment , months that therapists demonstrate monthly competency , and adolescents who are in recovery following treatment . Similarly , cost-effectiveness outcomes will focus on cost per adolescent receiving targeted threshold level of treatment , cost per month of demonstrated competence , and cost per adolescent in recovery . Trial Registration Trial Registration Number : 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 BACKGROUND Many physicians receive financial incentives to limit their ordering of expensive tests and procedures . While Medicare m and ates disclosure of incentives , it is not clear how to inform patients without undermining trust . METHODS Our objective was to determine public opinion about physician  disclosure of financial incentives and how this might be best communicated to patients . The 2002 General Social Survey included 2765 interviews from a probability sample of English-speaking US households . The interview included questions about financial incentives and an audiotaped scenario of a physician discussing the impact of financial incentives on ordering a magnetic resonance image . Respondents heard 1 of 6 r and omly selected disclosure strategies . The measurements included ratings of trust , satisfaction , agreement with the physician 's decision , and likelihood of remaining with the physician/health plan or seeking a second opinion . RESULTS Nearly half ( 48.8 % ) of respondents had previously heard of financial incentives to limit test ordering . Of the respondents , 94.8 % wanted to be told about incentives , at the time of enrollment in a health plan ( 80.5 % ) , by a health plan representative ( 44.8 % ) , their physician ( 17.1 % ) , or both ( 38.1 % ) . Of the 6 different disclosure strategies , " addressing emotions " and " negotiation " were associated with the best outcomes , while " common enemy " and " denying influences " were most negatively perceived . Black and Hispanic subjects were less likely to express satisfaction or trust and more likely to disenroll or seek a second opinion . CONCLUSIONS The public wants information about physician financial incentives . Specific communication styles enhance how this information is conveyed to patients , increasing trust and supporting the physician-patient relationship
Results Current evidence indicates that incentives can be effective in driving health behaviour change under certain provisos , while a number of misgivings continue to be deliberated on .
Conclusion These key principles can assist policy makers in making decisions on the use of financial incentives directed at achieving improvements in public health
Background The use of financial incentives or pay-for-performance programs for health care providers has triggered emerging interest in the use of financial incentives for encouraging health behaviour change .
Purpose This paper aims to identify key conditions under which the use of financial incentives for improvements in public health outcomes is most likely to be effective and appropriate .