title: 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. Impact of financial incentives on documented immunization rates in the inner city: results of a randomized controlled trial. Effect of the vaccines for children program on inner-city neighborhood physicians. 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. 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. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice.
abstract: 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 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 OBJECTIVE To determine the probable effect of the  Vaccines for Children ( VFC ) program on immunization coverage . DESIGN Preintervention and postintervention study design , with data collected before and after enrollment in the VFC program . SETTING Twenty-three inner-city neighborhood physicians ' offices in New York City . PARTICIPANTS In 1993 , 30 physicians were r and omly selected from 8 neighborhoods with the highest proportions of Medicaid-eligible individuals in New York City . In 1995 - 1996 , the 30 physicians were contacted again . Twenty-three agreed to an interview and medical record review . Within each office , the medical records of children aged 3 to 35 months , with at least 3 visits in a 3-month or longer period , were r and omly selected . Medical record review s were conducted for 173 eligible children in 1993 and 528 in 1995 - 1996 . INTERVENTIONS The VFC program was implemented in October 1994 . The administration fee increased from $ 2 to $ 17.85 ; physicians received vaccines free . MAIN OUTCOME MEASURES Up-to- date status for immunizations and lead and tuberculosis screening ; percentage of visits that are missed opportunities to immunize ; and percentage of visits that were well-child visits . Up-to- date status , missed opportunities to immunize , and well-child visits were compared across time using chi 2 analysis , corrected for the use of cluster sampling . RESULTS Up-to- date status changed significantly before and alter enrollment in the VFC program ( P < .05 ) for all immunizations and for lead and tuberculosis screening . For the diphtheria toxoid , tetanus toxoid , and pertussis vaccine , oral poliovirus vaccine , and measles , mumps , and rubella vaccine combined , coverage increased from 17.9 % to 42.2 % , up by 24.3 percentage points ( P < .05 ) . Missed opportunities to immunize did not change , but well-child visits increased from 15.0 % to 21.6 % ( P < .05 ) . Physicians generally attributed performance improvements to the VFC program and not to other competing hypotheses . CONCLUSIONS The VFC program seems to be responsible for an increase in immunization rates among these physicians 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 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 OBJECTIVE To determine the effectiveness of different types of interventions in improving  health professional performance and health outcomes . DATA SOURCES MEDLINE , SCI SEARCH , CINAHL and the Research and Development Re source Base in CME were search ed for trials of  educational interventions in the health care professions published between 1970 and 1993 inclusive . STUDY SELECTION Studies were selected if they provided objective measurements of  health professional performance or health outcomes  and employed r and om or quasi-r and om allocation methods in their study design s to assign individual subjects or groups . Interventions included such activities as conferences , outreach visits , the use of local opinion leaders , audit and feedback , and reminder systems . DATA EXTRACTION Details extracted from the studies included the study design ; the unit of allocation ( e.g. , patient , provider , practice , hospital ) ; the characteristics of the targeted health care professionals , educational interventions and patients ( when appropriate ) ; and the main outcome measure . DATA SYNTHESIS The inclusion criteria were met by 102 trials . Areas of behaviour change included general patient management , preventive services , prescribing practice s , treatment of specific conditions such as hypertension or diabetes , and diagnostic service or hospital utilization . Dissemination-only strategies , such as conferences or the mailing of unsolicited material s , demonstrated little or no changes in health professional behaviour or health outcome when used alone . More complex interventions , such as the use of outreach visits or local opinion leaders , ranged from ineffective to highly effective but were most often moderately effective ( result ing in reductions of 20 % to 50 % in the incidence of inappropriate performance ) . CONCLUSION There are no " magic bullets " for improving the quality of health care , but there are a wide range of interventions available that , if used appropriately , could lead to important improvements in professional practice and patient outcomes
target: The intervention sites admitted statistically significantly more severely ill patients  than nursing homes in the control group .
  Despite the
background: In the report Crossing the Quality Chasm ( 1 ) , the Institute of Medicine called attention to the poor quality of health care in the United States .
  The Institute identified numerous factors contributing to poor quality , including the structure of the present health care payment system .
  The Institute found that , for certain clinical situations , health care payment arrangements may actually produce disincentives for quality .
  The largely untapped potential of the health care payment system to change physician and health care system behavior has stimulated interest in both the scientific literature ( 2 , 3 ) and the popular press ( 4 - 6 ) for linking payments to performance on quality measures .
  Several health plans ( 3 , 7 ) and the Centers for Medicare & Medicaid Services are using explicit financial incentives for quality ( 8 , 9 ) .
  For example , what types of clinical conditions or health care services should be the target of financial incentives to improve quality : chronic diseases , acute care , or preventive care services ?
  How effective ( and cost-effective ) are financial incentives for quality ?
  What are the optimum magnitude , frequency , and duration of financial incentives for quality ?
  What is the optimum package of nonfinancial interventions ( if any ) to include with financial incentives for quality , for example , audit and feedback , recognition , clinical reminders , academic detailing , or information technology support ( 12 , 13 ) ?
  Can we expect the effect of financial incentives to persist after they are stopped ?
  Because any effective intervention will have some unanticipated effects , will important patient care activities that are not rewarded financially be neglected ?
  The purpose of this paper is to assess the relationship between explicit financial incentives and the provision of high- quality health care by systematic ally review ing empirical studies .
  Because the evidence regarding the relationship between the financial incentives embedded in fee-for-service and capitation arrangements and the quality of health care has been thoroughly review ed in previous work ( 14 ) , we focused our review on literature that addresses explicit financial rewards for improving health care quality .
  Methods Study Identification and Selection We conducted a systematic search of the English- language literature in PubMed to find articles published between 1 January 1980 and 14 November 2005 whose main objective was to assess the use of explicit financial incentives to improve health care quality .
  Access to care is the patient 's attainment of timely and appropriate health care .
  Structure of care is a feature of a health care organization or clinician relevant to the provision of health care .
  Process of care is a health care service provided to or on behalf of a patient .
  Outcome of care is a health state of a patient result ing from health care .
  Concurrent comparison groups are important because some studies of quality may show dramatic improvement over time but no statistically significant differences between intervention and comparison groups .