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An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes
Open accessAbstract
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 reviews 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 reviews that evaluates the impact of financial incentives on healthcare professional behaviour and patient outcomes. METHODS: We searched the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library); Database of Abstracts of Reviews of Effectiveness (DARE); TRIP; MEDLINE; EMBASE; Science Citation Index; Social Science Citation Index; NHS EED; HEED; EconLit; and Program in Policy Decision-Making (PPd) (from their inception dates up to January 2010). We searched the reference lists of all included reviews and carried out a citation search of those papers which cited studies included in the review. We included both Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs), controlled clinical trials (CCTs), interrupted time series (ITSs) and controlled before and after studies (CBAs) that evaluated the effects of financial incentives on professional practice and patient outcomes, and that reported numerical results of the included individual studies. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR criteria. We included systematic reviews of studies evaluating the effectiveness of any type of financial incentive. We grouped financial incentives into five groups: payment for working for a specified time period; payment for each service, episode or visit; payment for providing care for a patient or specific population; payment for providing a pre-specified level or providing a change in activity or quality of care; and mixed or other systems. We summarised data using vote counting. MAIN RESULTS: We identified four reviews reporting on 32 studies. Two reviews scored 7 on the AMSTAR criteria (moderate, score 5 to 7, quality) and two scored 9 (high, score 8 to 11, quality). The reported quality of the included studies was, by a variety of methods, low to moderate. Payment for working for a specified time period was generally ineffective, improving 3/11 outcomes from one study reported in one review. Payment for each service, episode or visit was generally effective, improving 7/10 outcomes from five studies reported in three reviews; payment for providing care for a patient or specific population was generally effective, improving 48/69 outcomes from 13 studies reported in two reviews; payment for providing a pre-specified level or providing a change in activity or quality of care was generally effective, improving 17/20 reported outcomes from 10 studies reported in two reviews; and mixed and other systems were of mixed effectiveness, improving 20/31 reported outcomes from seven studies reported in three reviews. When looking at the effect of financial incentives overall across categories of outcomes, they were of mixed effectiveness on consultation or visit rates (improving 10/17 outcomes from three studies in two reviews); generally effective in improving processes of care (improving 41/57 outcomes from 19 studies in three reviews); generally effective in improving referrals and admissions (improving 11/16 outcomes from 11 studies in four reviews); generally ineffective in improving compliance with guidelines outcomes (improving 5/17 outcomes from five studies in two reviews); and generally effective in improving prescribing costs outcomes (improving 28/34 outcomes from 10 studies in one review). AUTHORS' CONCLUSIONS: Financial incentives may be effective in changing healthcare professional practice. The evidence has serious methodological limitations and is also very limited in its completeness and generalisability. We found no evidence from reviews that examined the effect of financial incentives on patient outcomes.
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“Costly pay-for-performance interventions appear to influence short-term GP behaviour change, but not long-term, and do not appear to translate to improved patient outcomes [63,64].”
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Bergenholtz, H., Hølge-Hazelton, B., & Jarlbaek, L. (2015) · BMC Palliative Care · doi:10.1186/s12904-015-0022-2 · Cited by 19
“Research has shown that financial support in health care may have an effect in changing the practice of healthcare professionals when a payment is given for each service, but without evidence in patient outcome [35].”
BackgroundA literature review on integrating quality and safety into hospital pricing systems
Eagar, K., Sansoni, J., Loggie, C. L., Elsworthy, A. M., McNamee, J. P., Cook, R. L., & Grootemaat, P. E. (2013) · Research Online (University of Wollongong) · Cited by 18
Lentz, T. A., Harman, J. S., Marlow, N. M., & George, S. Z. (2017) · PubMed · doi:10.2522/ptj.20160167 · Cited by 17
DePasse, J. V., Smith, K. J., Raviotta, J. M., Shim, E., Nowalk, M. P., Zimmerman, R. K., & Brown, S. T. (2016) · American Journal of Epidemiology · doi:10.1093/aje/kww229 · Cited by 18
“Financial incentives either for achieving higher vaccination rates or for increasing choice are one option, as research has shown that financial incentives can affect clinical practice (32, 33) and are generally effective for providing a change in activity or quality of care (34).”
BackgroundYordanov, D., Oxholm, A. S., Gyrd‐Hansen, D., & Pedersen, L. B. (2023) · British Journal of General Practice · doi:10.3399/bjgp.2022.0563 · Cited by 19
Variability in screening prevention activities in primary care in Spain: a multilevel analysis
Rosell‐Murphy, M., Rodríguez-Blanco, T., Morán, J., Pons‐Vigués, M., Elorza, J. M., Rodríguez, J. C., Pareja, C., Nuin, M. Á., & Bolíbar, B. (2015) · BMC Public Health · doi:10.1186/s12889-015-1767-5 · Cited by 16
“With regard to financial incentives, evidence suggests that they might be effective in changing the practice of healthcare professionals [46].”
BackgroundSilva, J. M., Stein, A. T., Schünemann, H. J., Bordin, R., Kuchenbecker, R., & Drachler, M. D. L. (2013) · BMC Pregnancy and Childbirth · doi:10.1186/1471-2393-13-68 · Cited by 16
Performance-related-pay in the UK public sector
Bajorek, Z., & Bevan, S. (2015) · Journal of Organizational Effectiveness People and Performance · doi:10.1108/joepp-03-2015-0011 · Cited by 16
Strategies for Improving Vaccine Delivery: A Cluster-Randomized Trial
Fu, L. Y., Zook, K., Gingold, J. A., Gillespie, C. W., Briccetti, C., Cora‐Bramble, D., Joseph, J. G., Haimowitz, R., & Moon, R. Y. (2016) · PEDIATRICS · doi:10.1542/peds.2015-4603 · Cited by 16
The integration of health and social care services.
Pike, B., & Mongan, D. (2014) · Lenus, The Irish Health Repository (Dr Steevens Hospital Library) · Cited by 16
Clarke, L., Anderson, M., Anderson, R., Klausen, M. B., Forman, R., Kerns, J., Rabe, A. P. J., Kristensen, S. R., Theodorakis, P. N., Valderas, J. M., et al. (2021) · Milbank Quarterly · doi:10.1111/1468-0009.12536 · Cited by 18
Cheng, A. H. Y., & Sutherland, J. M. (2013) · Health Policy · doi:10.1016/j.healthpol.2013.07.010 · Cited by 15
Beidas, R. S., & Stirman, S. W. (2020) · Psychiatric Services · doi:10.1176/appi.ps.202000257 · Cited by 15
Archambault, P. M., Turgeon, A. F., Witteman, H. O., Lauzier, F., Moore, L., Lamontagne, F., Horsley, T., Gagnon, M., Droit, A., Weiss, M. J., et al. (2015) · JMIR Research Protocols · doi:10.2196/resprot.4024 · Cited by 15
“Getting new evidence into health care practice is a slow and challenging process [57-65].”
Krauth, C., Liersch, S., Jensen, S., & Amelung, V. E. (2016) · Health Policy · doi:10.1016/j.healthpol.2016.01.009 · Cited by 16
Jones, A., Pierce, M., Sutton, M., Mason, T., & Millar, T. (2017) · Addiction · doi:10.1111/add.13960 · Cited by 15
Mason, A., Liu, D., Kasteridis, P., Goddard, M. K., Jacobs, R., Wittenberg, R., & McGonigal, G. (2018) · International Journal of Geriatric Psychiatry · doi:10.1002/gps.4897 · Cited by 15
“Whilst some interventions were designed to improve dementia care directly, financial incentives have been shown to be powerful levers in effecting behavioural changes in primary and secondary care.(9,10) The aim of this study was to evaluate the impact of these financial incentives on diagnostic rates of dementia in p…”
BackgroundRide, J., Kasteridis, P., Gutacker, N., Kronenberg, C., Doran, T., Mason, A., Rice, N., Gravelle, H. S. E., Goddard, M. K., Kendrick, T., et al. (2018) · BMJ Open · doi:10.1136/bmjopen-2018-023135 · Cited by 15
Brocklehurst, P. R., Tickle, M., Birch, S., McDonald, R., Walsh, T., Goodwin, T. L., Hill, H. R., Howarth, E., Donaldson, M., O’Carolan, D., et al. (2020) · Health Services and Delivery Research · doi:10.3310/hsdr08060 · Cited by 15
“In medicine, a review of reviews found that serious methodological limitations restricted the completeness and generalisability of the evidence for how changing remuneration systems affected patient care.(2) There was also insufficient evidence to determine the effect of financial incentives on the quality of health c…”
BackgroundAllison, R., Lecky, D. M., Beech, E., Costelloe, C., Ashiru-Oredope, D. A. I., Owens, R., & McNulty, C. A. M. (2020) · JAC-Antimicrobial Resistance · doi:10.1093/jacamr/dlaa020 · Cited by 15
Paying for performance in healthcare organisations
McDonald, R. (2014) · International Journal of Health Policy and Management · doi:10.15171/ijhpm.2014.14 · Cited by 14
“In economic and some health policy literatures, there has been a tendency to treat FIs as a ‘standard’ intervention, with researchers attempting to draw conclusions about the effectiveness of these in terms of improving quality in healthcare (7).”
BackgroundMoosa, S., Luiz, J. M., Carmichael, T., Peersman, W., & Derese, A. (2016) · African Journal of Primary Health Care & Family Medicine · doi:10.4102/phcfm.v8i1.1025 · Cited by 14
Izón, G. M., & Pardini, C. A. (2017) · Applied Health Economics and Health Policy · doi:10.1007/s40258-017-0357-3 · Cited by 14
Creating and Breaking Habit in Healthcare Professional Behaviours to Improve Healthcare and Health
Potthoff, S., McCleary, N., Sniehotta, F. F., & Presseau, J. (2018) · Springer eBooks · doi:10.1007/978-3-319-97529-0_14 · Cited by 14
Ramos‐Morcillo, A. J., Ruzafa‐Martínez, M., Fernández‐Salazar, S., Casado, R. D. P., & Armero‐Barranco, D. (2014) · Atención Primaria · doi:10.1016/j.aprim.2014.02.002 · Cited by 14
“…de que exista una presión entre iguales, así como la aprobación por parte de Con respecto al control conductual percibido, sería inte-resante 27 28 29 24 reali-zar este tipo de actividades Por último, sería interesante realizar formación, reuniones educativas 27 , auditorías y…”
Impact of pay for performance on behavior of primary care physicians and patient outcomes
Lin, Y., Yin, S., Huang, J., & Du, L. (2015) · Journal of Evidence-Based Medicine · doi:10.1111/jebm.12185 · Cited by 14
“Considering all above, other factors, besides P4P, need to be considered so that the clinical performance can objectively be evaluated and truly improved on the basis of diverse baselines, which was similar to the previous studies (52, 53).”
ResultChen, T., Lai, M., & Chung, K. (2015) · International Journal for Quality in Health Care · doi:10.1093/intqhc/mzv098 · Cited by 14
Integrated community case management of childhood illness in low- and middle-income countries
Oliphant, N. P., Daniels, K., Odendaal, W., Besada, D., Manda, S., Kinney, M. V., Johansson, E. W., Lunze, K., Johansen, M., & Doherty, T. (2017) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd012882 · Cited by 14
Integrated Funding: Connecting the Silos for the Healthcare We NeedPreprint
Sutherland, J. M., & Hellsten, E. (2017) · SSRN Electronic Journal · doi:10.2139/ssrn.2901658 · Cited by 14
“A large and varied body of research confirms that different ways of paying for health services – such as salary, fee for service, and per case payments – have different effects on the way care is delivered (Gosden et al. 2000; Flodgren et al. 2011).”
Eccles, M., Shepperd, S., Scott, A., Flodgren, G., Parmelli, E., & Beyer, F. R. (2011) · Cochrane Database of Systematic Reviews · doi:10.1002/14651858.cd008608.pub2 · Cited by 14
Self-citation
Metadata
- Authors
- Flodgren, G., Eccles, M. P., Shepperd, S., Scott, A., Parmelli, E., & Beyer, F. R.
- Affiliations
- University of Oxford (GB)
- Newcastle University (GB)
- The University of Melbourne (AU)
- University of Modena and Reggio Emilia (IT)
- University of York (GB)
- Venue
- Cochrane Database of Systematic Reviews
- Publisher
- Wiley
- Published
- 2011-07-06
- Volume
- 2011
- Issue
- 7
- Pages
- CD009255-CD009255
- ISSN
- 1361-6137 (ISSN-L)
- 1465-1858
- PMC
- PMC4204491
- OpenAlex
- W1875145339
- Cited by
- 418
- References
- 83
- Citations by year
- 2026: 5 · 2025: 19 · 2024: 20 · 2023: 10 · 2022: 23 · 2021: 32 · 2020: 27 · 2019: 29 · 2018: 30 · 2017: 49 · 2016: 29 · 2015: 44 · 2014: 41 · 2013: 39 · 2012: 17
- FWCI
- 5.36
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Cochrane Database of Systematic Reviews (publishedVersion)
- Europe PMC (PubMed Central) (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Newcastle University ePrints (Newcastle Univesity)
- Funders
- National Institute for Health and Care Research (10/4001/03)
- Topics
- Health Sciences › Medicine › Family Practice › Primary Care and Health Outcomes
- Social Sciences › Economics, Econometrics and Finance › Economics and Econometrics › Healthcare Policy and Management
- Health Sciences › Health Professions › General Health Professions › Health Policy Implementation Science
- Keywords
- financial incentives, healthcare professional behaviour, patient outcomes, performance-based pay, fee-for-service, quality of care, evidence-based practice, extrinsic motivation, health care delivery, vote counting, health policy evaluation, health professions education, health professions workforce
- MeSH terms
- Capitation Fee, Delivery of Health Care, Humans, Motivation, Professional Practice, Review Literature as Topic, Salaries and Fringe Benefits, Treatment Outcome, Fee-for-Service Plans
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