title: Addition of generic medication vouchers to a pharmacist academic detailing program: effects on the generic dispensing ratio in a physician-hospital organization. Clinical and economic consequences of a reimbursement restriction of nebulised respiratory therapy in adults: direct comparison of randomised and observational evaluations Understanding the effects of a decentralized budget on physicians' compliance with guidelines for statin prescription – a multilevel methodological approach Effects of Medicare Part D coverage gap on medication and medical treatment among elderly beneficiaries with depression. Recorded quality of primary care for patients with diabetes in England before and after the introduction of a financial incentive scheme: a longitudinal observational study GP fundholding and the costs of prescribing: further results. Effects of the German 1993 health reform law upon primary care practitioners' individual performance: results from an empirical study in sentinel practices. The extent of the two tier service for fundholders [Drug prescribing in primary health care for diabetic and non-diabetic patients: effect of therapeutic drug budgeting]. Prospective study of trends in referral patterns in fundholding and non-fundholding practices in the Oxford region, 1990-4 Does the frequency of pay-for-performance payment matter?--Experience from a randomized trial. The effects of fundholding in general practice on prescribing habits three years after introduction of the scheme
abstract: BACKGROUND Generic dispensing ratio ( GDR ) is an important measure of efficiency in pharmacy benefit management . A few studies have examined the effects of academic detailing or generic drug sample s on GDR . On July 1 , 2007 , a physician-hospital organization ( PHO ) with a pay-for-performance incentive for generic utilization initiated a pilot generic medication voucher program that augmented its existing pharmacist-led academic detailing efforts . No published studies have examined the role of generic medication vouchers in promoting generic drug utilization . OBJECTIVE To determine if supplementing an existing academic detailing initiative in a PHO with a generic medication voucher program would be more effective in increasing the GDR compared with academic detailing alone . METHODS The intervention took place over the 9-month period from July 1 , 2007 , through March 31 , 2008 .  Vouchers provided patients with the first fill of a 30-day supply of a generic drug at no cost to the patient for 8 specific generic medications obtained through a national community pharmacy chain . The study was conducted in a PHO composed of 7 hospitals and approximately 2,900 physicians ( 900 primary care providers [ PCPs ] and 2,000 specialists ) . Of the approximately 300 PCP practice s , 21 practice s with at least 2 physicians each were selected on the basis of high prescription volume ( more than 500 pharmacy cl aims for the practice over a 12-month pre-baseline period ) and low GDR ( practice GDR less than 55 % in the 12-month pre-baseline period ) . These 21 practice s were then r and omized to a control group of academic detailing alone or the intervention group that received academic detailing plus generic medication vouchers . One of 10 intervention groups declined to participate , and 2 of 11 control groups dropped out of the PHO . GDR was calculated monthly for all pharmacy cl aims including the 8 voucher medications . GDR was defined as the ratio of the total number of paid generic pharmacy cl aims divided by the total number of paid pharmacy cl aims for 108 prescriber identification numbers ( Drug Enforcement Administration [ DEA ] or National Provider Identifier [ NPI ] ) for 9 intervention groups [ n = 53 PCPs ] and 9 control groups [ n = 55 PCPs ] ) . For both intervention and control arms , the GDR for each month from July 2007 ( start of 2007 Q3 , intervention start date ) through September 2008 ( end of 2008 Q3 , 6 months after intervention end date ) was compared with the same month in the previous year . A descriptive analysis compared a 9-month baseline period from 2006 Q3 through 2007 Q1 with a 9-month voucher period from 2007 Q3 to 2008 Q1 . A panel data regression analysis assessed GDR for 18 practice s over 27 months ( 12 months pre-intervention and 15 months post-intervention ) . RESULTS A total of 656 vouchers were redeemed over the 9-month voucher period from July 1 , 2007 , through March 31 , 2008 , for an average of about 12 vouchers per participating physician ; approximately one-third of the redeemed vouchers were for generic simvastatin . The GDR increase for all drugs , including the 8 voucher drugs , was 7.4 points for the 9 PCP group practice s with access to generic medication vouchers , from 53.4 % in the 9-month baseline period to 60.8 % in the 9-month voucher period , compared with a 6.2 point increase for the control group from 55.9 % during baseline to 62.1 % during the voucher period . The panel data regression model estimated that the medication voucher program was associated with a 1.77-point increase in overall GDR compared with academic detailing alone ( P = 0.047 ) . CONCLUSION Compared with academic detailing alone , a generic medication voucher program providing a 30-day supply of 8 specific medications in addition to academic detailing in PCP groups with low GDR and high prescribing volume in an outpatient setting was associated with a small but statistically significant increase in adjusted overall GDR Abstract Objective To compare the results of a r and omised and an observational evaluation of the same policy that restricted reimbursement for nebulised respiratory medications in adult patients in a community setting . Design s Cluster r and omised controlled trial and observational time series with historical controls . Setting Pharmacare , the government funded drug benefits plan for elderly people and patients receiving social assistance in British Columbia , Canada . Participants In the r and omised controlled trial 104 clusters of medical practice s , pair matched by geography and approximately by practice size , were r and omised to the intervention group ( 449 patients affected by the policy on 1 March 1999 ) , and the control group ( offered a six month exemption , affecting 386 patients ) . The observational analysis included all Pharmacare beneficiaries ( excluding the 386 exempt patients ) who had used any nebulised drugs six months before the policy ( 4624 patients ) . Intervention Pharmacare restricted reimbursement for nebulised bronchodilators , steroids , and cromoglycate to patients whose doctors applied for an individual patient 's exemption , giving an appropriate clinical reason . Main outcome measures Number of contacts with doctors and services , emergency admissions to hospital , and utilisation of and expenditure for respiratory drugs in data bases of British Columbia 's Ministry of Health . Results Contacts with doctors or emergency admissions to hospital did not increase in association with the restriction , regardless of the analytical approach . In the observational analysis , we found a reduction of $ C24 per patient month in all nebulised drug use ( 95 % confidence interval 19 to 29 ) and an increase of $ C3 per patient month in all expenditure for inhalers ( 1.4 to 4.5 ) . The r and omised evaluation found savings of $ C8 per patient month for nebulisers ( P = 0.24 ) and no increase in spending on inhalers ( P = 0.79 ) . Correcting for 60 % non-compliance by exempt doctors in a sensitivity analysis yielded similar results as the observational evaluation . Conclusions Observational as well as r and omised analyses found moderate net savings and no increase in unintended healthcare outcomes after restricting reimbursement for nebulised respiratory drugs . R and omised policy trials are feasible and , if carefully implemented , likely to be concordant with observational evaluations Background Official guidelines that promote evidence -based and cost-effective prescribing are of main relevance for obvious reasons . However , to what extent these guidelines are followed and their conditioning factors at different levels of the health care system are still insufficiently known . In January 2004 , a de central ized drug budget was implemented in the county of Scania , Sweden . Focusing on lipid-lowering drugs ( i.e. , statins ) , we evaluated the effect of this intervention across a 25-month period . We expected that increased local economic responsibility would promote prescribing of recommended statins . Methods We performed two separate multilevel regression analyses ; on 110 827 individual prescriptions issued at 136 publicly-administered health care centres ( HCCs ) nested within 14 administrative areas ( HCAs ) , and on 72 012 individual prescriptions issued by 115 privately-administered HCCs . Temporal trends in the prevalence of prescription of recommended statins  were investigated by r and om slope analysis . Differences ( i.e. , variance ) between HCCs and between HCAs were expressed by median odds ratio ( MOR ) . Results After the implementation of the de central ized drug budget , adherence to guidelines increased continuously . At the end of the observation period , however , practice variation remained high . Prescription of recommended statins presented a high degree of clustering within both publicly ( i.e. , MORHCC = 2.18 and MORHCA = 1.31 respectively ) and privately administered facilities ( MORHCC = 3.47 ) . Conclusion A de central ized drug budget seems to promote adherence to guidelines for statin prescription . However , the high practice differences at the end of the observation period may reflect inefficient therapeutic traditions , and indicates that rational statin prescription could be further improved CONTEXT Maintenance antidepressant pharmacotherapy in late life prevents recurrent episodes of major depression . The coverage gap in Medicare Part D could increase the likelihood of reducing appropriate use of antidepressants , thereby exposing older adults to an increased risk for relapse of depressive episodes . OBJECTIVES To determine whether ( 1 ) beneficiaries reduce antidepressant use in the gap , ( 2 ) the reduction in antidepressant use is similar to the reduction in heart failure medications and antidiabetics , ( 3 ) the provision of generic coverage reduces the risk of reduction of medication use , and ( 4 ) medical spending increases in the gap . DESIGN Observational before-after study with a comparison group design . SETTING AND PATIENTS A 5 % r and om sample of US Medicare beneficiaries 65 years or older with depression ( n = 65,223 ) enrolled in st and -alone Part D plans in 2007 . MAIN OUTCOME MEASURES  Antidepressant pharmacotherapy , physician , outpatient , and inpatient spending . RESULTS Being in the gap was associated with comparable reductions in the use of antidepressants , heart failure medications , and antidiabetics . Relative to the comparison group ( those who had full coverage in the gap because of Medicare coverage or low-income subsidies ) , the no-coverage group reduced their monthly antidepressant prescriptions by 12.1 % ( 95 % CI , 9.9%-14.3 % ) from the pregap level , whereas they reduced use of heart failure drugs and antidiabetics by 12.9 % and 13.4 % , respectively . Those with generic drug coverage in the gap reduced their monthly antidepressant prescriptions by 6.9 % ( 95 % CI , 4.8%-9.1 % ) ; this decrease was entirely attributable to the reduction in the use of br and -name antidepressants . Medicare spending on medical care did not increase for either group relative to the comparison group . CONCLUSIONS The Medicare Part D coverage gap was associated with modest reductions in the use of antidepressants . Those with generic coverage reduced their use of br and -name drugs and did not switch from br and -name to generic drugs . The reduction in antidepressant use was not associated with an increase in nondrug medical spending Background The UK 's Quality and Outcomes Framework ( QOF ) was introduced in 2004/5 , linking remuneration for general practice s to recorded quality of care for chronic conditions , including diabetes mellitus . We assessed the effect of the incentives on recorded quality of care for diabetes patients and its variation by patient and practice characteristics . Methods Using the General Practice Research Data base we selected a stratified sample of 148 English general practice s in Engl and , contributing data from 2000/1 to 2006/7 , and obtained a r and om sample of 653 500 patients in which 23 920 diabetes patients identified . We quantified annually recorded quality of care at the patient-level , as measured by the 17  QOF diabetes indicators , in a composite score and analysed it longitudinally using an Interrupted Time Series design . Results Recorded quality of care improved for all subgroups in the pre-incentive period . In the first year of the incentives , composite quality improved over- and -above this pre-incentive trend by 14.2 % ( 13.7–14.6 % ) . By the third year the improvement above trend was smaller , but still statistically significant , at 7.3 % ( 6.7–8.0 % ) . After 3 years of the incentives , recorded levels of care varied significantly for patient gender , age , years of previous care , number of co-morbid conditions and practice diabetes prevalence . Conclusions The introduction of financial incentives was associated with improvements in the recorded quality of diabetes care in the first year . These improvements included some measures of disease control , but most captured only documentation of recommended aspects of clinical assessment , not patient management or outcomes of care . Improvements in subsequent years were more modest . Variation in care between population groups diminished under the incentives , but remained substantial in some cases 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 An empirical study in Lower Saxony aim ed to investigate any changes in primary care physicians ' diagnostic and therapeutic strategies as a result of Germany 's 1993 health reform act ( known as the Gesundheitsstruktur Gesetz or GSG ) , which included the countrywide implementation of a strict drug budget . A sentinel network consisting of a 37 % sample of 350 r and omly selected doctors ( n = 130 , GPs , general internists ) was established in Lower Saxony . Four cross sectional surveys , each focussing on one group of health problems , were carried out during 1993 . These aim ed to show whether sentinel practice networks are suitable for reporting physicians ' attitudes towards health care cost containment policies and , secondly , changes in physicians ' quantitative and qualitative assessment s of the 1993 reform act during its first year of implementation . Participating physicians reported patient consultations ( n = 3728 ) . St and ardised question naires ascertained sociodemographic variables and major reasons for the patients ' visit . Data on the diagnoses associated with the patient 's main reason for the consultation , the doctor 's assessment of the severity of the problem , and diagnostic and treatment strategies were also recorded . The question naire focussed on changes in therapy made by the physician together with the reasons for these changes . A number of treatment changes made with regard to cost containment were recorded . During the course of 1993 a decrease in reported changes in treatment was noticed . As expected , some doctors recorded a reduction in successful outcomes of treatment and ascribed this to the reform act . Differences between the four surveys with regard to the influence of the health reform act on the frequency of changes in treatment and the physicians ' expectations can not be explained sufficiently by the physicians ' adaptation to the cost containment policies within the year 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 With computerised data on drug prescriptions , which were collected among a sample of 362 internist , general and medical practitioners throughout Germany , the effects of the drug budget , based on the German Health Care Structure Reform Act ( GSG ) , on diabetic patients were analysed . The data of 3053 diabetic patients ( 10 % r and om sample ) were compared with the same number of nondiabetic patients for the period of July 1992 to December 1994 . The frequency of consultations per patient increased in both groups during the study period ( p < 0.01 ) . Diabetic patients had more contacts with the physicians than nondiabetic subjects ( p < 0.01 ) . The prescriptions and costs among the patients with diabetes decreased in the first six month of 1993 ( -10%/ -16 % ) . In the following time costs increased and exceeded the values of 1992 by about 13 % . The costs per prescription decreased during the study period about 10 % . The data show that costs as well as prescriptions per consultation between diabetic and nondiabetic patients remained in the same ratio . The proportion of consultations with > or = 1 prescription increased in diabetic patients after the GSG . A refusal to prescribe drugs in primary health care practice s among diabetic patients was not observed . There was also no restriction on prescription drug use among diabetic patients compared with nondiabetics Abstract Objective : To compare  outpatient referral patterns in fundholding and non-fundholding practice s before and after the NHS reforms in April 1991 . Design : Prospect i ve collection of data on general practitioners ' referrals to specialist outpatient clinics between June 1990 and January 1994 and detailed comparisons of three phases -- October 1990 to March 1991 ( phase 1 ) , October 1991 to March 1992 ( phase 2 ) , and October 1993 to January 1994 ( phase 3 ) . Setting : 10 first wave fundholding practice s and six non-fundholding practice s in the Oxford region . Subjects : Patients referred to consultant outpatient clinics . Results : NHS referral rates increased in fundholding practice s in phase 2 and phase 3 of the study by 8.1/1000 patients a year ( 95 % confidence interval 5.7 to 10.5 ) , anincrease of 7.5 % from phase 1 ( 107.3/1000 ) to phase 3 ( 115.4/1000 ) . Non-fundholders ' rates increased significantly , by 25.3/1000 patients ( 22.5 - 28.1 ) , an increase of 26.6 % from phase 1 ( 95.0/1000 ) to phase 3 ( 120.3/1000 ) . The fundholders ' referral rates to private clinics decreased by 8.8 % , whereas those from non-fundholding practice s increased by 12.2 % . The proportion of referrals going outside district boundaries did not change significantly . Three of the four practice s entering the third and fourth wave of fundholding increased their referral rates significantly in the year before becoming fundholders . Conclusions : No evidence existed that budgetary pressures caused first wave fundholders to reduce referral rates , although the method of budget allocation may have encouraged general practitioners to inflate their referral rates in the preparatory year . Despite investment in new practice based facilities , no evidence yet exists that fundholdingencourages a shift away from specialist care OBJECTIVE To examine the effects of incentive payment frequency on quality measures in a physician-specific pay-for-performance ( P4P ) experiment . STUDY SETTING A multispecialty physician group practice . STUDY DESIGN In 2007 , all primary care physicians ( n=179 ) were r and omized into two study arms differing by the frequency of incentive payment , either four quarterly bonus checks or a single year-end bonus ( maximum of U.S.$5,000/year for both arms ) . DATA COLLECTION / EXTRACTION METHODS Data were extracted from electronic health records . Quality measure scores between the two arms over four quarters were compared . PRINCIPAL FINDINGS There was no difference between the two arms in average quality measure score or in total bonus amount earned . CONCLUSIONS Physicians ' responses to a P4P program with a small maximum bonus do not differ by frequency of bonus payment Abstract Objectives : To observe changes in prescribing practice that occurred after the introduction of fundholding in first wave practice s and to contrast these with changes occurring in similar nonfundholding practice s. Design : Prospect i ve observational study . Setting : Oxford region fundholding study . Subjects : Eight first wave fundholding practice s and five practice s that were not interested in fundholding in 1990 - 1 , which were similar in terms of practice size , training status , locality , and urban rural mix . Three of the fundholding and none of the non-fundholding practice s were dispensing practice s. Main outcome measures : Changes in prescribing practice as measured by net cost per prescribing unit , cost per item , number of items prescribed , and substitution rates for generic drugs three years after the introduction of fundholding . Data for fundholding practice s were analysed separately according to whether they were dispensing or non-dispensing practice s. Results : Prescribing costs rose by a third or more in all types of practice . The patterns of change observed in this cohort after one year of fundholding were reversed . No evidence existed that fundholding had controlled prescribing costs among non-dispensing fundholders ; costs among dispensing fundholders rose least , but the differences were small compared with the overall increase in costs . Conclusions : Early reports of the effectiveness of  fundholding  in curbing prescribing costs have not been confirmed in this longer term study
target: Although financial incentives are considered an important element in strategies to change prescribing patterns , limited evidence of their effects can be found .
background: BACKGROUND The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories .
  Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care .
  Financial incentives seeking to influence prescribers ' behaviour include budgetary arrangements at primary care and hospital setting s ( pharmaceutical budget caps or targets ) , financial rewards for target behaviours or outcomes ( pay for performance interventions ) and reduced benefit margin for prescribers based on medicine sales and prescriptions ( pharmaceutical reimbursement rate reduction policies ) .
  This is the first up date of the original version of this review .
  OBJECTIVES To determine the effects of pharmaceutical policies using financial incentives to influence prescribers ' practice s on drug use , healthcare utilisation , health outcomes and costs ( expenditures ) .