Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Financial Incentives

Intervention Description: A retrospective review of administrative data was done to evaluate a natural quasi-experiment in a network of publicly funded primary care clinics. Physicians in 6 of 11 clinics were given a financial incentive twice the size of the current Centers for Medicare and Medicaid Services' incentive for achieving group targets in preventive care that included cervical cancer screening, mammography, and pediatric immunization. They also received productivity incentives. Six years of performance indicators were compared between incentivized and nonincentivized clinics. We also surveyed the incentivized clinicians about their perception of the incentive program.

Intervention Results: Although some performance indicators improved for all measures and all clinics, there were no clinically significant differences between clinics that had incentives and those that did not. A linear trend test approached conventional significance levels for Papanicolaou smears (P = .08) but was of very modest magnitude compared with observed nonlinear variations; there was no suggestion of a linear trend for mammography or pediatric immunizations. The survey revealed that most physicians felt the incentives were not very effective in improving quality of care.

Conclusion: We found no evidence for a clinically significant effect of financial incentives on performance of preventive care in these community health centers. Based on our findings and others, we believe there is great need for more research with strong research designs to determine the effects, both positive and negative, of financial incentives on clinical quality indicators in primary care.

Study Design: QE: concurrent comparison group

Setting: Eleven safety-net community health centers in Houston/Harris County, TX (Community Health Program [CHP])

Population of Focus: Practicing CHP physicians

Data Source: Chart review

Sample Size: Approximate total (N≈110) N=physicians Total (N=12,495) Intervention (n=7,411); Control (n=5,084) N=charts reviewed

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): PATIENT/CONSUMER, Patient Reminder/Invitation, Educational Material, PROVIDER/PRACTICE, Provider Reminder/Recall Systems, Financial Incentives, Nurse/Nurse Practitioner

Intervention Description: Before-and-after comparisons of the time-appropriate delivery rates of cervical and breast cancer screening using the automated and NP-augmented strategies of the P-PROMPT reminder and recall system.

Intervention Results: Before-and-after comparisons of time-appropriate delivery rates (< 30 months) of cancer screening showed the rates of Pap tests and mammograms for eligible women significantly increased over a 1-year period by 6.3% (P < .001) and 5.3% (P < .001), respectively. The NP-augmented strategy achieved comparable rate increases to the automated strategy alone in the delivery rates of both services.

Conclusion: The use of provider and patient reminders and pay-for-performance incentives resulted in increases in the uptake of Pap tests and mammograms among eligible primary care patients over a 1-year period in family practices in Ontario.

Setting: Eight primary care network practices and 16 family health network practices in southwestern Ontario

Population of Focus: Practicing physicians from the participating primary care network and family health network groups

Data Source: CytoBase (consortium of main laboratories in Ontario), combined with rosters of eligible patients

Sample Size: Total (N=246) Analysis (n=232) N=physicians

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Financial Incentives, Incentives

Intervention Description: This study evaluates a Target gift card incentive employed by a Minnesota health plan serving Medicaid beneficiaries over the period 2002-2003.

Intervention Results: The dichotomous intervention variable suggested that those living within about 2.5 miles of a Target store were about 3% more likely to have a visit than those living farther than 2.5 miles. The dichotomous variable, however, indicated that this represents a smaller decline in well-child visits, rather than an increase. This was due to the fact that for those living near a Target store, the percentage receiving the incentive declined from 37.06% to 35.82% in transitioning from the pre- to post-implementation period, respectively, and for those living far from a Target store, the percentages declined from 32.03% to 28.42%. Thus, the unadjusted difference-in-differences calculation was 2.024, indicating that the decline in wellchild visits would have been greater were it not for the incentive.

Conclusion: Using alternative specifications for the intervention variable, results of the difference-in-differences equations suggest that the incentive program significantly increased the likelihood that a Medicaid beneficiary would have a well-child visit.

Study Design: N/A

Setting: N/A

Data Source: N/A

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Family-Based Interventions, Financial Incentives, Food Prescriptions

Intervention Description: The intervention involves providing additional fruit and vegetable vouchers to pregnant Women, Infants, and Children (WIC) clients as a strategy to improve food security and diet quality. The study aimed to assess the impact of this intervention on food insecurity and fruit and vegetable intake among pregnant WIC clients.

Intervention Results: Participants in intervention and comparison counties completed surveys at enrollment and approximately three months later (n = 609). Mean ± SD food insecurity at baseline was 3.67 ± 2.79 and 3.47 ± 2.73 in the intervention and comparison groups, respectively, and the adjusted between-group change from baseline to follow-up in food insecurity was 0.05 [95% CI: −0.35, 0.44] (p > 0.05). F&V intake (in cup equivalents) was 2.56 ± 0.95 and 2.51 ± 0.89 at baseline in the two groups, and the adjusted mean between-group difference in changes from baseline was −0.06 [−0.23, 0.11] (p > 0.05). Recruitment and data collection for this study coincided with the most intensive of America’s COVID relief efforts. Our results may indicate that small increases in highly targeted food resources make less of a difference in the context of larger, more general resources being provided to individuals and households in need.

Conclusion: Our results may indicate that small increases in highly targeted food resources make less of a difference in the context of larger, more general resources being provided to individuals and households in need.

Study Design: comparion group

Setting: San Francisco, California

Population of Focus: Pregnant individuals with low income enrolled in the Women, Infants, and Children (WIC) program.

Sample Size: 770

Age Range: 26-35

Intervention Components (click on component to see a list of all articles that use that intervention): PROVIDER/PRACTICE, Financial Incentives

Intervention Description: The study evaluated a natural experiment with pay-for-performance using administrative reports of physician group quality from a large health plan for an intervention group (California physician groups) and a contemporaneous comparison group (Pacific Northwest physician groups). Quality improvement reports were included from October 2001 through April 2004 issued to approximately 300 large physician organizations. Main outcome measures: Three process measures of clinical quality: cervical cancer screening, mammography, and hemoglobin A1c testing.

Intervention Results: Improvements in clinical quality scores were as follows: for cervical cancer screening, 5.3% for California vs 1.7% for Pacific Northwest; for mammography, 1.9% vs 0.2%; and for hemoglobin A1c, 2.1% vs 2.1%. Compared with physician groups in the Pacific Northwest, the California network demonstrated greater quality improvement after the pay-for-performance intervention only in cervical cancer screening (a 3.6% difference in improvement [P = .02]). In total, the plan awarded 3.4 million dollars (27% of the amount set aside) in bonus payments between July 2003 and April 2004, the first year of the program. For all 3 measures, physician groups with baseline performance at or above the performance threshold for receipt of a bonus improved the least but garnered the largest share of the bonus payments.

Conclusion: Paying clinicians to reach a common, fixed performance target may produce little gain in quality for the money spent and will largely reward those with higher performance at baseline.

Study Design: QE: pretest-posttest non-equivalent control group

Setting: PacifiCare medical groups in California and the Pacific Northwest

Population of Focus: Physician groups

Data Source: PacifiCare physician group performance reports

Sample Size: Intervention (n=163); Control (n=42) N=physician groups

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): Consultation (Parent/Family), Financial Incentives, Referrals,

Intervention Description: Poverty is a common root cause of poor health and disrupts medical care. Clinically embedded antipoverty programs that address financial stressors may prevent missed visits and improve show rates. This pilot study evaluated the impact of clinic-based financial coaching on adherence to recommended preventive care pediatric visits and vaccinations in the first 6 months of life. In this community-partnered randomized controlled trial comparing clinic-based financial coaching to usual care among low-income parent-infant dyads attending pediatric preventive care visits, we examined the impact of the longitudinal financial intervention delivered by trained coaches addressing parent-identified, strengths-based financial goals (employment, savings, public benefits enrollment, etc.). We also examined social needs screening and resource referral on rates of missed preventive care pediatric visits and vaccinations through the 6-month well-child visit.

Intervention Results: Eighty-one parent-infant dyads were randomized (35 intervention, 46 control); nearly all parents were mothers and more than one-half were Latina. The rate of missed visits among those randomized to clinic-based financial coaching was half that of controls (0.46 vs 1.07 missed of 4 recommended visits; mean difference, 0.61 visits missed; P = .01). Intervention participants were more likely to have up-to-date immunizations each visit (relative risk, 1.26; P = .01) with fewer missed vaccinations by the end of the 6-month preventive care visit period (2.52 vs 3.8 missed vaccinations; P = .002).

Conclusion: In this pilot randomized trial, a medical-financial partnership embedding financial coaching within pediatric primary care improved low-income families' adherence to recommended visits and vaccinations. Clinic-based financial coaching may improve care continuity and quality in the medical home.

Study Design: Randomized controlled trial

Setting: Pediatric primary care clinic at Harbor-UCLA, an academically affiliated safety net medical center and second largest in Los Angeles County’s Department of Health Services

Population of Focus: Low-income parent-infant dyads presenting to pediatric primary care clinics for scheduled, non-acute primary care visits

Sample Size: 81 parent-infant dyads, with 35 dyads assigned to the intervention group receiving clinic-based financial coaching and 46 dyads assigned to the control group receiving usual care

Age Range: The participants included English- and Spanish-speaking adult parents and their infants younger than 4 months of age