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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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Multidisciplinary tuberculosis care: leveraging the role of hospital pharmacists
Iskandar, D., Pradipta, I. S., Anggriani, A., Postma, M. J., & van Boven, J. F. M. (2023) · BMJ Open Respiratory Research · doi:10.1136/bmjresp-2023-001887 · Cited by 5
“Around one-third of hospital pharmacists were involved in multidisciplinary TB care, and one-quarter had TB- specific tasks.”
BackgroundMokhtary, S., Janati, A., Yousefi, M., & Raei, B. (2024) · Journal of Education and Health Promotion · doi:10.4103/jehp.jehp_873_23 · Cited by 5
“[49] Nonetheless, much uncertainty still exists about the relationship between value‑based payment effects and patient outcomes including mortality or quality of care.”
BackgroundLee, Y., Kim, S., & Chae, Y. (2019) · PLoS ONE · doi:10.1371/journal.pone.0218154 · Cited by 5
Strategies to engage family physicians in primary care research: A systematic review
Girard, A., Dugas, M., Lépine, J., Carnovale, V., Jalbert, L., Turmel, A., Stefan, T., Poirier, A.-A., Mailhot, B., Skidmore, B., et al. (2022) · Journal of Evaluation in Clinical Practice · doi:10.1111/jep.13733 · Cited by 5
Wyffels, E., Beles, M., Baeyens, A., Croeckaert, K., Potter, T. J. R. D., Camp, G. V., Collet, C. A., Sonck, J., Vanderheyden, M., Bartúnek, J., et al. (2023) · Health Policy · doi:10.1016/j.healthpol.2023.104826 · Cited by 5
Financial incentive schemes in primary care
Gillam, S. (2015) · Journal of Healthcare Leadership · doi:10.2147/jhl.s64365 · Cited by 5
“An overview of four systematic reviews in health care found that none had examined the effect on patient outcomes.(36) Evidence of physician activity does not always correspond to better health outcomes.”
Improving the Quality of Family Planning Services: The Role of New Federal Recommendations
Gavin, L. E., & Moskosky, S. B. (2014) · Journal of Women s Health · doi:10.1089/jwh.2014.4865 · Cited by 5
Evidence Brief: Developing a National Pain Strategy for Canada
Waddell, K., Moat, K. A., & Lavis, J. N. (2017) · MacSphere (McMaster University) · Cited by 5
Gupta, N., & Ayles, H. M. (2020) · Human Resources for Health · doi:10.1186/s12960-020-00512-9 · Cited by 5
“Such incentives, also known as pay-for-performance (P4P), may be offered as added rewards to healthcare practitioners for changes in clinical behaviors in terms of time, services delivered, patients reached, quantity or quality of care, continuity of care, or other established targets to achieve health system goals [1…”
BackgroundRole of financial incentives in family planning services in India: a qualitative study
Lalchandani, K., Gupta, A., Srivastava, A., Usmanova, G., Maadam, A., & Sood, B. (2021) · BMC Health Services Research · doi:10.1186/s12913-021-06799-1 · Cited by 5
“Whilst for patients, FI is believed to be an encouraging factor in uencing the uptake and compliance to the prescribed services [1].”
BackgroundInfluentialVilendrer, S. M., Brown‐Johnson, C. G., Kling, S. M. R., Veruttipong, D., Amano, A., Bohman, B. D., Daines, W. P., Overton, D., Srivastava, R., & Asch, S. M. (2021) · The Annals of Family Medicine · doi:10.1370/afm.2719 · Cited by 6
Woodfield, M. J., Merry, S., & Hetrick, S. E. (2022) · Implementation Research and Practice · doi:10.1177/26334895221082330 · Cited by 5
“Extrinsic source of motivation, conditional on performing a particular behaviour or set of behaviours, though may inadvertently reduce intrinsic motivation (Flodgren et al., 2011).”
BackgroundStructural characteristics and contractual terms of specialist palliative homecare in Germany
Jansky, M. K., Heyl, L., Hach, M., Kranz, S. J., Lehmann, T., Freytag, A., Wedding, U., Meißner, W., Krauss, S. H., Schneider, W., et al. (2023) · BMC Palliative Care · doi:10.1186/s12904-023-01274-6 · Cited by 5
“As they determine the revenues obtained by a team to cover the cost of care provision, the reimbursement schemes may influence the type and quality of care [10, 11].”
BackgroundThe Effect of Financial and Educational Incentives on Rational Prescribing. A State-Space Approach
Pechlivanoglou, P., Wieringa, J. E., de Jager, T., & Postma, M. J. (2014) · Health Economics · doi:10.1002/hec.3030 · Cited by 5
“…target improvements in quality of care, a number of P4P interventions aim directly at the reduction of prescribing costs (Beaulieu and Horrigan, 2005; Sheldon, 2006; Fuhrmans, 2008; Comma et al ., 2009; Boonen et al ., 2010; Godman et al ., 2010; Flodgren et al ., 2011; Godman et al ., 2011).”
BackgroundDoes patient health behaviour respond to doctor effort?
Fichera, E., Banks, J., Siciliani, L., & Sutton, M. (2018) · Journal of Economic Behavior & Organization · doi:10.1016/j.jebo.2018.10.014 · Cited by 5
“(2012)) and on the effort of doctors (Flodgren et al. (2011); Gravelle et al.”
BackgroundMethodInfluentialReddy, S. (2017) · Journal of Primary Health Care · doi:10.1071/hc17014 · Cited by 5
How May Neuroscience Affect the Way that the Criminal Courts Deal with Addicted Offenders?
Hall, W., & Carter, A. (2013) · Oxford University Press eBooks · doi:10.1093/acprof:oso/9780199925605.003.0012 · Cited by 5
Incentives to Follow Best Practice in Health CarePreprint
Schaffer, S. K., Sussex, J., & Feng, Y. (2015) · SSRN Electronic Journal · doi:10.2139/ssrn.2640041 · Cited by 5
Identifying psychosocial and contextual markers considered by physicians to personalize care
Domenach, P., Krause, K. R., Malmartel, A., Ravaud, P., & Tran, V.-T. (2024) · BMC Medicine · doi:10.1186/s12916-024-03616-4 · Cited by 4
“The development of standardized personalization will facilitate the analysis of care quality by using concordance with recommended care and avoiding inadequate reward or penalization of physicians through performance payment policies that do not account for patients’ circumstances [38, 39].”
MethodA cost-reducing reimbursement programme? Effects of value-based reimbursement on healthcare costs
Eriksson, T., Tropp, H., Wiréhn, A.-B., & Levin, L. (2024) · Frontiers in Public Health · doi:10.3389/fpubh.2024.1326067 · Cited by 4
Jochum, F., Doll, M., Hamy, A., Donval, L., Gougis, P., Dumas, É., Lecointre, L., Gaillard, T., Reyal, F., Lecuru, F. R., et al. (2025) · EClinicalMedicine · doi:10.1016/j.eclinm.2024.103053 · Cited by 4
Kalmus, O., Chalkley, M., & Listl, S. (2021) · The European Journal of Health Economics · doi:10.1007/s10198-021-01348-3 · Cited by 4
“Empirical evidence, however, remains weak that these goals are easily achieved [14, 15].”
BackgroundThe effects of introducing an electronic prescription system with no copayments
Eriksen, I. I., & Melberg, H. O. (2015) · Health Economics Review · doi:10.1186/s13561-015-0056-4 · Cited by 4
“Background A recurring theme in the literature on physicians’ behaviour is the extent to which physicians are influenced by changes in incentives as opposed to pure medical considerations [1–3].”
Financial and Clinical Risk in Health Care Reform: A View from Below
Smith, P. A., MACKINTOSH, M. M., Ross, F., Clayton, J., Price, L., Christian, S., Byng, R., & Allan, H. T. (2012) · Journal of Health Services Research & Policy · doi:10.1258/jhsrp.2012.011100 · Cited by 4
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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