title: Physician reimbursement by salary or fee-for-service: effect on physician practice behavior in a randomized prospective study. Knowledge transfer for the management of dementia: a cluster-randomised trial of blended learning in general practice The Use of Physician Financial Incentives and Feedback to Improve Pediatric Preventive Care in Medicaid Managed Care Frequency and characteristics of cognitive services provided in response to a financial incentive. Development, feasibility and performance of a health risk appraisal questionnaire for older persons Changing remuneration systems: effects on activity in general practice. Impact of financial incentives on documented immunization rates in the inner city: results of a randomized controlled trial. The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. The feasibility of creating a checklist for the assessment of the methodological quality both of randomised and non-randomised studies of health care interventions. Physician financial incentives and feedback: failure to increase cancer screening in Medicaid managed care. GP fundholding and the costs of prescribing: further results. The extent of the two tier service for fundholders Prepayment with office-based physicians in publicly funded programs: results from the Children's Medicaid Program. Performance-based physician reimbursement and influenza immunization rates in the elderly. The Primary-Care Physicians of Monroe County. Incentives for Community Treatment Mental Illness Management Services Enhancing mammography referral in primary care. The impact of physician bonuses, enhanced fees, and feedback on childhood immunization coverage rates.
abstract: We used a  resident continuity clinic  to compare prospect ively the impact of salary v fee-for-service reimbursement on physician practice behavior . This model allowed r and omization of physicians into salary and fee-for-service groups and separation of the effects of reimbursement from patient behavior . Physicians reimbursed by fee-for-services scheduled more visits per patient than did salaried physicians ( 3.69 visits v 2.83 visits , P less than .01 ) and saw their patients more often ( 2.70 visits v 2.21 visits , P less than .05 ) during the 9-month study . Almost all of this difference was because fee-for-service physicians saw more well patients than salaried physicians ( 1.42 visits and .99 visits per enrolled patient , respectively , P less than .01 ) . Evaluating visits by American Academy of Pediatrics ' guidelines indicated that fee-for-service physicians saw more patients for well-childcare than salaried physicians because they missed fewer recommended visits and scheduled visits in excess of those recommendations . Fee-for-service physicians also provided better continuity of care than salaried physicians by attending a larger percentage of all visits made by their patients ( 86.6 % of visits v 78.3 % of visits , P less than .05 ) , and by encouraging fewer emergency visits per enrolled patient ( 0.12 visits v 0.22 visits , P less than .01 ) . Physicians ' interest in private practice , as determined by their career plans , correlated significantly with total number of patients enrolled ( r = .48 , P less than .05 ) and total clinic patients seen by each resident during the study ( r = .40 , P less than .05 ) . ( ABSTRACT TRUNCATED AT 250 WORDS Background The implementation of new medical knowledge into general practice is a complex process . Blended learning may offer an effective and efficient educational intervention to reduce the knowledge-to- practice gap . The aim of this study was to compare knowledge acquisition about dementia management between a blended learning approach using online modules in addition to quality circles ( QCs ) and QCs alone . Methods In this cluster-r and omised trial with QCs as clusters and general practitioners ( GPs ) as participants , 389 GPs from 26 QCs in the western part of Germany were invited to participate . Data on the GPs ' knowledge were obtained at three points in time by means of a question naire survey . Primary outcome was the knowledge gain before and after the interventions . A subgroup analysis of the users of the online modules was performed . Results 166 GPs were available for analysis and filled out a knowledge test at least two times . A significant increase of knowledge was found in both groups that indicated positive learning effects of both approaches . However , there was no significant difference between the groups . A subgroup analysis of the GPs who self-reported that they had actually used the online modules showed that they had a significant increase in their knowledge scores . Conclusion A blended learning approach was not superior to a QCs approach for improving knowledge about dementia management . However , a subgroup of GPs who were motivated to actually use the online modules had a gain in knowledge . Trial registration Current Controlled Trials IS RCT N36550981 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 OBJECTIVE To determine the effects of a financial incentive on the number and types of  cognitive services ( CS )  provided by community pharmacies to Medicaid recipients in the State of Washington . DESIGN Prospect i ve r and omized trial . CS were reported using a problem-intervention- result coding system over a 20-month period . SETTING AND SUBJECTS Pharmacists practicing in 110 study ( financial incentive ) and 90 control community pharmacies . RESULTS Study pharmacists documented an average of 1.59 CS interventions per 100 prescriptions over a 20-month period , significantly more than controls , who documented an average of 0.67 interventions ( P < .05 ) per 100 prescriptions . One-half ( 48.4 % ) of all CS were for patient-related problems , 32.6 % were for drug-related problems , 17.6 % were for prescription-related problems , and 1.4 % were for other problems that did not involve drug therapy . A change in drug therapy occurred as a result of 28 % of all CS documented in this demonstration . Changes were rarely ( 2.4 % ) due to generic or therapeutic substitution and almost always ( 90 % ) followed communication with the prescriber . The average self-reported time to perform CS was 7.5 minutes ; 75 % of interventions were < or = 6 minutes . Considerable differences existed between study and control groups in the types of problems identified , intervention activities performed , and results of interventions . CONCLUSION A financial incentive was associated with significantly more , and different types of , CS performed by pharmacists Background Health risk appraisal is a promising method for health promotion and prevention in older persons . The Health Risk Appraisal for the Elderly ( HRA-E ) developed in the U.S. has unique features but has not been tested outside the United States . Methods Based on the original HRA-E , we developed a scientifically up date d and regionally adapted multilingual Health Risk Appraisal for Older Persons ( HRA-O ) instrument consisting of a self-administered question naire and software-generated feed-back reports . We evaluated the practicability and performance of the question naire in non-disabled community-dwelling older persons in London ( U.K. ) ( N = 1090 ) , Hamburg ( Germany ) ( N = 804 ) , and Solothurn ( Switzerl and ) ( N = 748 ) in a sub- sample of an international r and omised controlled study . Results Over eighty percent of invited older persons returned the self-administered HRA-O question  naire . Fair or poor self-perceived health status and older age were correlated with higher rates of non-return of the question naire . Older participants and those with lower educational levels reported more difficulty in completing the HRA-O question naire as compared to younger and higher educated persons . However , even among older participants and those with low educational level , more than 80 % rated the question naire as easy to complete . Prevalence rates of risks for functional decline or problems were between 2 % and 91 % for the 19 HRA-O domains . Participants ' intention to change health behaviour suggested that for some risk factors participants were in a pre-contemplation phase , having no short- or medium-term plans for change . Many participants perceived their health behaviour or preventative care uptake as optimal , despite indications of deficits according to the HRA-O based evaluation . Conclusion The HRA-O question naire was highly accepted by a broad range of community-dwelling non-disabled persons . It identified a high number of risks and problems , and provided information on participants ' intention to change health behaviour OBJECTIVE --To investigate the effects on general practitioners ' activities of a change in their remuneration from a capitation based system to a mixed fee per item and capitation based system . DESIGN --Follow up study with data collected from contact sheets completed by general practitioners in one period before ( March 1987 ) a change in their remuneration system and two periods after ( March 1988 , November 1988 ) , with a control group of general practitioners with a  mixed fee per item and capitation based system  throughout . SETTING --General practice s in Copenhagen city ( index group ) and Copenhagen county ( control group ) . SUBJECTS--265 General practitioners in Copenhagen city , of whom 100 were selected r and omly from the 130 who agreed to participate ( 10 exclusions ) and 326 general practitioners in Copenhagen county . MAIN OUTCOME MEASURES --Number of consultations ( face to face and by telephone ) and renewals of prescriptions , diagnostic and curative services , and specialist and hospital referrals per 1000 enlisted patients in one week . RESULTS --Of the 75 general practitioners who completed all three sheets , four were excluded for incomplete data . Total contact rates per 1000 patients listed rose significantly compared with the rates before the change index in the city ( 100.0 before the change v 111.7 ( 95 % confidence interval 106.4 to 117.4 after the change ) and over the same time in the control group ( 100.0 v 106.0 ) , but within a year these rates fell ( to 104.2(99.1 to 109.6 ) and 104.0 respectively ) . There was an increase in consultations by telephone initially but not thereafter . Rates of examinations and treatments that attracted specific additional remuneration after the change rose significantly compared with those before ( diagnostic services , 138.1 ( 118.7 to 160.5 ) and 159.5 ( 137.8 to 184.7 ) and curative services 194.6 ( 152.2 to 248.9 ) and 194.8(152.3 to 249.2 ) for second and third data collection s respectively ) and with the control group ( diagnostic services 105.3 , 107.6 and curative services 106.0 , 115.0 ) whereas referral rates to secondary care fell ( specialist referrals 90.1 ( 80.7 to 100.6 ) and 77.0 ( 68.6 to 86.4 ) and hospital referrals 87.4 ( 71.1 to 107.5 ) and 68.4 ( 54.7 to 85.4 ] in doctors in the city . CONCLUSIONS --Introducing a partial fee for service system seemed to stimulate the provision of services by general practitioners , result ing in reduced referral rates . The concept of a " target income " which doctors aim at , rather than maximising their income seemed to play a part in adjustment to changing the system of remuneration OBJECTIVE This study determined the effect of 2 financial incentives --- bonus and enhanced fee-for-service --- on documented immunization rates during a second period of observation . METHODS Incentives were given to 57 r and omly selected inner-city physicians 4 times at 4-month intervals based on the performance of 50 r and omly selected children . Coverage from linked records from all sources was determined for a sub sample of children within physician offices . RESULTS Up-to- date coverage rates documented in the charts increased significantly for children in the bonus group ( 49.7 % to 55.6 % ; P < .05 ) and the enhanced fee-for-service group ( 50.8 % to 58.2 % ; P < .01 ) compared with the control group . The number of immunizations given by these physicians did not change significantly , although the number of immunizations given by others and documented by physicians in the bonus group did increase ( P < .05 ) . Up-to- date coverage for all groups increased from 20 to 40 percentage points when immunizations from physician charts were combined with other sources . CONCLUSIONS Both financial incentives produced a significant increase in coverage levels . Increases were primarily due to better documentation not to better immunizing practice s. The financial incentives appeared to provide motivation to physicians but were not sufficient to overcome entrenched behavior patterns . However , true immunization coverage was substantially higher than that documented in the charts 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 OBJECTIVE : To test the feasibility of creating a valid and reliable checklist with the following features : appropriate for assessing both r and omised and non-r and omised studies ; provision of both an overall score for study quality and a profile of scores not only for the quality of reporting , internal validity ( bias and confounding ) and power , but also for external validity . DESIGN : A pilot version was first developed , based on epidemiological principles , review s , and existing checklists for r and omised studies . Face and content validity were assessed by three experienced review ers and reliability was determined using two raters assessing 10 r and omised and 10 non-r and omised studies . Using different raters , the checklist was revised and tested for internal consistency ( Kuder-Richardson 20 ) , test-retest and inter-rater reliability ( Spearman correlation coefficient and sign rank test ; kappa statistics ) , criterion validity , and respondent burden . MAIN RESULTS : The performance of the checklist improved considerably after revision of a pilot version . The Quality Index had high internal consistency ( KR-20 : 0.89 ) as did the subscales apart from external validity ( KR-20 : 0.54 ) . Test-retest ( r 0.88 ) and inter-rater ( r 0.75 ) reliability of the Quality Index were good . Reliability of the subscales varied from good ( bias ) to poor ( external validity ) . The Quality Index correlated highly with an existing , established instrument for assessing r and omised studies ( r 0.90 ) . There was little difference between its performance with non-r and omised and with r and omised studies . Raters took about 20 minutes to assess each paper ( range 10 to 45 minutes ) . CONCLUSIONS : This study has shown that it is feasible to develop a checklist that can be used to assess the method ological quality not only of r and omised controlled trials but also non-r and omised studies . It has also shown that it is possible to produce a checklist that provides a profile of the paper , alerting review ers to its particular method ological strengths and weaknesses . Further work is required to improve the checklist and the training of raters in the assessment of external validity OBJECTIVES A r and omized controlled trial evaluated the impact of feedback and financial incentives on physician compliance with cancer screening guidelines for women 50 years of age and older in a Medicaid health maintenance organization ( HMO ) . METHODS Half of 52 primary care sites received the intervention , which included written feedback and a financial bonus .  Mammography , breast exam , colorectal screening , and Pap testing compliance rates were evaluated . RESULTS From 1993 to 1995 , screening rates doubled overall ( from 24 % to 50 % ) , with no significant differences between intervention and control group sites . CONCLUSIONS Financial incentives and feedback did not improve physician compliance with cancer screening guidelines in a Medicaid HMO BACKGROUND An earlier paper published in this journal suggested that  fundholding practice s in Lincolnshire had managed to constrain the growth in their prescribing costs more successfully than had non-fundholders , largely on the basis of restricting the number of items prescribed per patient . At that time , insufficient data were available to explore the impact of a change in status from non-fundholding to fundholding on prescribing behaviour . METHOD Time-series prescribing data for the fourth-wave of Lincolnshire fundholders are analysed , and comparisons are made between this group , non-fundholders and the fundholders of the earlier waves . RESULTS In their first year of fundholding , fourth-wave practice s adopted the prescribing strategies employed previously by existing fundholders , namely , reductions in the number of items prescribed per patient and substantial increases in generic prescribing . The hypothesis that prospect i ve fundholders inflate their prescribing budget before attaining fundholding status is not generally supported by the Lincolnshire data . Evidence is presented which suggests that the prescribing cost economies accruing to fundholding status may be short term . CONCLUSIONS With the acquisition of fundholding status , the structure of incentives facing practice s changes . Our results suggest that , with respect to prescribing , practice s adjust rapidly to the new incentive structure 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 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 OBJECTIVE To investigate the effect of performance-based financial incentives on the  influenza immunization rate in primary care physicians ' offices . DESIGN R and omized controlled trial during the 1991 influenza immunization season . SETTING Rochester , New York , and surrounding Monroe County during the Medicare Influenza Vaccine Demonstration Project . PARTICIPANTS A total of 54 solo or group practice s that had participated in the 1990 Medicare Demonstration Project . INTERVENTIONS All physicians in participating practice s agreed to enumerate their ambulatory patients aged 65 or older who had been seen during the 1990 or 1991 calendar years , and to track the immunization rate on a weekly basis using a specially design ed poster from September 1991 to January 1 , 1992 . Additionally , physicians agreed to be r and omized , by practice group , to the control group or to the incentive group , which could receive an additional $ .80 per shot or $ 1.60 per shot if an immunization rate of 70 % or 85 % , respectively , was attained . MEASUREMENTS The main outcome measures are the 1991 immunization rate and the improvement in immunization rate from the 1990 to 1991 influenza seasons for each group practice . RESULTS For practice s in the incentive group , the mean immunization rate was 68.6 % ( SD 16.6 % ) compared with 62.7 % ( SD 18.0 % ) in the control group practice s ( P = .22 ) . The median practice -specific improvement in immunization rate was + 10.3 % in the incentive group compared with + 3.5 % in the control group ( P = .03 ) . CONCLUSIONS Despite high background immunization rates , this modest financial incentive was responsible for approximately 7 % increase in immunization rate among the ambulatory elderly Serving people with mental and other chronic illnesses in community setting s may improve compliance and satisfaction with treatment , but existing payment mechanisms often favor office-based treatment . This study examines the effect of a change in Medicaid payment on the location and amount of service provided by case managers . Amounts of service given by treatment providers to 185 of their clients in community setting s and in mental health centers were compared before and after reimbursement changed from an all-inclusive prospect i ve rate to a mixed prospect ive/retrospective payment . Clients were enrolled in two different treatment programs : continuous treatment teams with extensive training in in vivo treatment , and a case management program that emphasized office-based treatment .  In-community service increased , and the amount of office-based treatment decreased . Continuous treatment teams increased in-community services more than case managers did ; case managers decreased office-based treatment more . There was no change in total amount of services provided . It was concluded that mixed prospect i ve and retrospective reimbursement can remove financial barriers to in-community treatment , but it works best in combination with a training program . Additional research is needed to determine the precise financial impact of such changes BACKGROUND This 1-year r and omized trial tested the efficacy of behavioral techniques for increasing mammography referrals by primary care physicians in small , community practice s. METHODS Sixty-one practice s were r and omly assigned to one of three conditions : ( 1 ) education-only control , ( 2 ) education plus cue enhancement using mammography chart stickers , and ( 3 ) education plus cue enhancement plus feedback and token rewards . Quarterly chart audits of a defined sample ( N = 11,716 ) of women patients 50 years of age or older were conducted to document mammography referrals , completions , and compliance . RESULTS Referral and completion rates increased from baseline to first quarter and gradually declined thereafter . Overall , these rates were higher in the cuing conditions than in the control condition . In contrast , compliance rates in both experimental conditions increased over the year while remaining static in the control condition , demonstrating a strong and continuing effect for cue enhancement . Compliance increases were greatest for physicians who were older , nonwhite , with a second speciality , in solo practice , not members of the AMA , not residency trained , and not board certified . CONCLUSIONS Chart stickers can significantly increase mammography utilization in small , community practice s. These practice s are an efficient route to reaching large numbers of older women in need of mammography screening OBJECTIVES The purpose of this study was to examine the effects on immunization coverage of 3 incentives for physicians -- a cash bonus for practice --wide increases , enhanced fee for service , and feedback . METHODS Incentives were applied at 4-month intervals over 1 year among 60 inner-city office-based pediatricians . At each interval , charts of 50 r and omly selected children between 3 and 35 months of age were review ed per physician . RESULTS The percentage of children who were up to date for diphtheria , tetanus , and pertussis and Haemophilus influenzae type b ; polio ; and measles-mumps-rubella immunization in the study 's bonus group improved by 25.3 percentage points ( P < .01 ) . No significant changes occurred in the other groups . However , percentage of immunizations received outside the participating practice also increased significantly in the bonus group ( P < .01 ) . Levels of missed opportunities to immunize were high in all groups and did not change over time . Physicians ' knowledge of contraindications was low . CONCLUSIONS Bonuses sharply and rapidly increased immunization cover-age in medical records . However , much of the increase was the result of better documentation . A bonus is a powerful incentive , but more structure or education may be necessary to achieve the desired results
target: Financial incentives may be effective in changing healthcare professional practice .
  We found no evidence from review s that examined the effect of financial incentives on patient outcomes
background: BACKGROUND There is considerable interest in the effectiveness of financial incentives in the delivery of health care .
  Incentives may be used in an attempt to increase the use of evidence -based treatments among healthcare professionals or to stimulate health professionals to change their clinical behaviour with respect to preventive , diagnostic and treatment decisions , or both .
  Financial incentives are an extrinsic source of motivation and exist when an individual can expect a monetary transfer which is made conditional on acting in a particular way .
  Since there are numerous review s performed within the healthcare area describing the effects of various types of financial incentives , it is important to summarise the effectiveness of these in an overview to discern which are most effective in changing health professionals ' behaviour and patient outcomes .
  OBJECTIVES To conduct an overview of systematic review s that evaluates the impact of financial incentives on healthcare professional behaviour and patient outcomes .