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PubMed1993

Insurance incentives for ambulatory surgery.

This study is an attempt to address both the extent to which surgical procedures on an outpatient basis substitute cost-effectively for inpatient procedures, and whether or not an insurance policy's financial incentives increase the volume of outpatient surgical procedures. In particular, given an insurance product of a given composition: What is the probability that the insured will have surgery? and if a surgery does take place, what is the probability that it will occur in an outpatient setting? Finally, the article assesses the implication of such products on the total cost of care by quantifying the insurance plans along two parameters, the relative user price for outpatient versus inpatient surgery and the absolute price for the inpatient surgery. The results indicate that insurance policies that offer relatively lower out-of-pocket payments for ambulatory surgery do not increase the probability that surgery will be done in the ambulatory setting. However, higher out-of-pocket payments for surgery, regardless of site, do reduce the surgery rate. There are other patient and market characteristics, especially the availability of freestanding surgery firms, that do influence the location of surgery.

Ambulatory Surgical Procedures↗
PubMed1996

Managing care, incentives, and information: an exploratory look inside the "black box" of hospital efficiency.

OBJECTIVE: We sought to estimate the impact of individual dimensions of hospitals' managed care strategies on the cost per hospital discharge. STUDY SETTING/DATA SOURCES: Thirty-seven member hospitals of seven health systems in the Pacific, Rocky Mountain, and Southwest regions of the United States were studied. STUDY DESIGN: Separate cross-sectional regression analyses of 21,135 inpatient discharges were performed in 1991 and 23,262 discharges in 1992. The multivariate model was estimated with hospital cost per discharge as the dependent variable. Model robustness was checked by comparing regression results at the individual discharge level with those at the level of the hospital/clinical condition pair. DATA COLLECTION/EXTRACTION METHODS: Information on hospitals' managed care strategies was provided by mail and phone survey of key informants in 1991 and 1992. Other hospital characteristics were collected from AHA Annual Survey data, and discharge data from hospital abstracting systems. PRINCIPAL FINDINGS: The pooled discharge analysis indicated three dimensions of hospital managed care strategy that consistently related to lower costs per hospital discharge: the proportion of hospital revenues derived from per case or capitation payment, the hospital's mechanisms for sharing information on resource consumption with clinicians, and the use of formalized, systematic care coordination mechanisms. CONCLUSIONS: Three strategies appear to hold promise for enhancing the efficiency of inpatient resource use: (1) "fixed price" hospital payment incentives, (2) hospital approaches to sharing resource use information with clinicians, and (3) the application of formal care management mechanisms for specific clinical conditions.

Aged↗
PubMed1989

Physicians as gatekeepers. The impact of financial incentives.

Incentives encouraging physicians to reduce their use of diagnostic tests are controversial. We studied physicians enrolled in an independent practitioner association who see both fee-for-service and prepaid (health maintenance organization [HMO]) patients concurrently. We asked the following questions: (1) Do physicians order fewer tests for their patients enrolled in an HMO relative to their patients seen on a fee-for-service basis? (2) Are any reductions in testing selective or indiscriminate? We reviewed the charts of 273 new patients, 167 enrolled in a fee-for-service system and 106 enrolled in an HMO, who were seen by 17 physicians "for a check-up," and graded test use as "indicated" or "discretionary." We used multiple logistic regression to control for the effects of patient age and sex. Patients in the HMO underwent fewer tests than did patients in the fee-for-service system, as well as fewer discretionary tests, but received the same proportion of preventive services. We conclude that physicians ordered fewer tests for patients in the HMO, apparently because of selective omission of discretionary tests. Physicians also did not reduce preventive services for patients in the HMO relative to all other physicians.

Adult↗
PubMed2001

Telephone subsidy: an effective incentive for successful participation in home memory monitor study.

CONTEXT: The Collaborative Home Infant Monitoring Evaluation (CHIME) study enrolled healthy term infants and 3 groups of infants considered to be at increased risk for sudden infant death syndrome to evaluate apnea and bradycardia events in the home. Mother-infant pairs without a telephone were ineligible for enrollment. OBJECTIVE: To determine whether mother-infant pairs who were offered a telephone subsidy would agree to enroll in CHIME and achieve protocol compliance rates comparable with those of matched subjects able to afford telephones. DESIGN: Thirty-one telephone subsidy subjects were retrospectively compared with 55 control subjects matched for study group, site, birth weight, and maternal race, age, and education. SETTING: Collaborative Home Infant Monitoring Evaluation clinical research centers in Honolulu, Hawaii, and Toledo, Ohio. INTERVENTION: Provision of telephone subsidy to otherwise eligible enrollees for CHIME. MAIN OUTCOME MEASURES: Frequency of compliance with protocol requirements for follow-up evaluations and for extent of home monitoring. RESULTS: Subsidy subjects achieved protocol completion rates that were comparable with those of control subjects, for developmental assessments at 56 and 92 weeks postconceptional age (PCA), and for the polysomnogram. Unexpectedly, however, subsidy subjects were more likely to have a developmental assessment at 44 weeks PCA (P =.02), as well as a cry analysis (P =.04). They were also more likely to use the CHIME home monitor for more hours during weeks 2 through 5 (P =.004), have a higher percentage using the monitor for 10 or more hours per week during weeks 2 through 5 (P =.009), and have a higher total number of days of monitor use throughout 6 months (P <.001). Mean cost of the subsidy was $3.25 per day of monitor use, and monitor use per day was directly related to total cost of the subsidy (P =.02). CONCLUSIONS: Telephone subsidy is an effective financial incentive. At least within the context of the CHIME study, telephone subsidy enhanced access to health care, and in some categories it resulted in enhanced protocol compliance.

Adult↗
PubMed2005

Intrapulmonary percussive ventilation vs incentive spirometry for children with neuromuscular disease.

BACKGROUND: Pulmonary infections can be life threatening for children with neuromuscular diseases who have impaired ability to clear secretions. Intrapulmonary percussive ventilation (IPV) is a pneumatic device that delivers air and aerosol to the lungs at frequencies of 200 to 300 cycles per minute at peak pressures from 20 to 40 cm H(2)O. Anecdotal reports and pilot studies show its safety and effectiveness in mobilizing secretions in patients with cystic fibrosis. OBJECTIVE: To test the hypothesis that IPV used in a pulmonary program for adolescents with neuromuscular disease would reduce the number of days of antibiotic use for pulmonary infection. METHODS: A randomized, controlled study was conducted to compare efficacy of IPV with incentive spirometry (IS) in reducing number of days of antibiotic use in adolescents with neuromuscular disease. The secondary endpoints were the number of respiratory infections, hospitalizations, and school days missed. RESULTS: A total of 18 patients were enrolled (9 IPV, 9 IS). Antibiotic use was significantly higher with IS (24/1000 patient-days) compared with IPV (0/1000 patient-days), (incidence rate ratio, 43; 95% confidence interval, 6-333). The IS group spent more days hospitalized (4.4/1000 patient-days vs 0/1000 patient-days) than the IPV group (incidence rate ratio, 8.5; 95% confidence interval, 1.1-67). The IPV group had 0 episodes of pneumonia or bacterial bronchitis compared with 3 events in the IS group, although this did not meet statistical significance. CONCLUSION: Intrapulmonary percussive ventilation as part of a preventive pulmonary regimen reduced days of antibiotic use and hospitalization for respiratory illness in adolescents with neuromuscular disease.

Absenteeism↗
PubMed1998

Physician knowledge, financial incentives and treatment decisions for depression.

BACKGROUND: Two important policy levers to affect health care delivery are financing and informational interventions. Unfortunately, these two approaches have not been considered simultaneously and little is known about how their effects compare. AIMS OF THE STUDY: This paper estimates the relative role of financial incentives (prepaid versus fee for service) and provider information (perceived knowledge of antidepressant medications and skill in counseling for depression) on quality of care for less and more severely depressed patients and their health and cost outcomes. METHODS: We develop a theoretical model of provider behavior and estimate a reduced form using a multinomial probit model with heteroskedastic covariances. The likely effects of changing provider knowledge about depression treatment in primary care are then simulated and contrasted with the effects of a shift toward prepaid managed care as opposed to fee-for-service care. The empirical model is estimated using data from the Medical Outcomes Study. RESULTS: We conclude that financing and information have different effects and that their combination can achieve the conflicting goals of improved health outcomes and reduced direct treatment goals. Moreover, including family income as one important dimension of social cost suggests that the combination of informational interventions and a shift to prepaid care may dominate either one intervention in isolation from a social cost perspective. Specifically regarding information, we found that increasing provider knowledge could have the highly desirable effect of greater targeting of treatments to sicker patients while not raising overall treatment rates much - a treatment pattern that many hoped managed care could achieve, but for which there has been little evidence. CONCLUSIONS: Our analysis illustrates the value of considering these widely different policy goals simultaneously. We learned that variation in physician knowledge generally had stronger associations with clinically relevant practice patterns for depression than did a complete change in financing strategy. The moderate change in perceived knowledge we simulated (not near the extremes of observed values of perceived knowledge) was associated with enough improvement in appropriateness of care to more than offset the reduction in appropriateness with a complete shift from fee-for-service to prepaid managed care. IMPLICATIONS FOR HEALTH POLICY: The paper demonstrates the importance of considering different interventions simultaneously. Combining informational and financial interventions simultaneously can achieve better quality of care and reduce health care costs, something neither intervention can in isolation.

Journal Article↗
PubMed1988

Barriers and incentives for primary care physicians in cancer prevention and detection.

The American Cancer Society estimates that nearly a million new cases of cancer will occur and that approximately a half million lives will be lost in 1987. These figures may double by the year 2000 primarily because of our aging population, with age being the leading risk factor for cancer. It is believed that the majority of cancer can either be prevented or treated successfully if it is diagnosed early. Primary care physicians and other health professionals delivering information on prevention and performing early diagnostic studies in various ambulatory settings represent the key to the reduced morbidity and mortality of cancer by virtue of their position in the health care delivery system within communities. Barriers and incentives for delivering these all important health measures are examined and suggestions are made for their accomplishment. It is recommended that the primary thrust should be toward the development of methodology which will allow the primary care physician to institute these measures in his regular medical practice and to coordinate them with other health maintenance and early diagnostic activities in the ambulatory setting.

Attitude of Health Personnel↗
PubMed1987

Barriers and incentives for primary-care physicians in cancer prevention and detection.

The American Cancer Society (ACS) estimates that nearly a million new cases of cancer will occur and that approximately 500,000 lives will be lost in 1987. These figures may double by the year 2000 primarily because of our aging population, with age being the leading risk factor for cancer. It is believed that most cancers can either be prevented or treated successfully if they are diagnosed early. Primary-care physicians and other health professionals delivering information on prevention and performing early diagnostic studies in various ambulatory settings represent the key to the reduced complications and mortality of cancer by virtue of their position in the health care delivery system within communities. Barriers and incentives for delivering these all important health measures are examined and suggestions are made for their accomplishment. It is recommended that the primary thrust should be toward the development of methodology which will allow the primary care physician to institute these measures in his regular medical practice and to coordinate them with other health maintenance and early diagnostic activities in the ambulatory setting.

Attitude of Health Personnel↗
PubMed1979

Effective clinical trials investigators and adequate incentives.

Because of the importance of randomized controlled trials in medical research and development, the most competent and qualified individuals from a variety of medical specialties are needed as investigators for these trials. Such people must be highly dedicated to the improvement of human health and they must also be cooperative and able to work in the highly disciplined atmosphere that such a trial demands. In order that the trial investigators be persons of high caliber, certain incentives must be guaranteed, such as recognition of one's contributions to the trial itself, publications, and opportunities to present study results at various meetings. University and medical school policies on promotion and tenure need to be reassessed bearing in mind the complexity of achieving optimal recognition of the individuals investigator's contributions to a clinical trial.

Clinical Trials as Topic↗
PubMedDate not supplied

Intermunicipal health care consortia in Brazil: strategic behavior, incentives and sustainability.

This article studies strategic behavior in municipal health care consortia where neighboring municipalities form a partnership to supply high-complexity health care. Each municipality partially funds the organization. Depending on the partnership contract, a free rider problem may jeopardize the organization. A municipality will default its payments if it can still benefit from the services, especially when political pressures for competing expenditure arise. The main result is that the partnership sustainability depends on punishment mechanisms to a defaulting member, the gains from joint provision of services and the overall economic environment. Possible solutions to the incentive problem are discussed.

Brazil↗
PubMed1996

Effects of a personal trainer and financial incentives on exercise adherence in overweight women in a behavioral weight loss program.

Exercise is important for long-term weight loss, but few studies have examined ways to improve exercise adherence in overweight subjects participating in a behavioral weight loss program. This paper presents two studies, one conducted at the University of Pittsburgh and one at the University of Minnesota, that sought to improve exercise adherence by exerting more direct control over the environmental antecedents and consequences controlling exercise. Study 1 investigated the use of a personal trainer who called participants regularly and met them at their home or office at scheduled times for a walk. Study 2 investigated the effect of a lottery incentive for exercise adherence. In both studies, the effect of these manipulations was examined in the context of a 24-week standard behavioral weight control program with three supervised exercise sessions per week. Neither intervention achieved statistically significant improvements in exercise adherence compared to control conditions, perhaps due in part to the limited statistical power of the studies. Future studies should focus on better understanding the barriers to exercise and designing behavioral interventions that address these barriers.

Adult↗
PubMed2005

"I love ballet": arts incentives for adolescent health and community development.

Art can be a transformative process that not only offers youth opportunities for self-expression, but enables them to connect to their communities as part of the healing process. Having a public role offers those who are often without power to have a voice and a presence. This chapter provides information on the Arts Incentives Program at the United South End Settlements, a therapeutic, arts-based youth and community development program working with high-risk girls ages eleven to eighteen. Young people engage in community building within the program and become agents of positive community change. In revitalizing their communities, they rebuild a sense of self as essential, valued, and creative, bringing together the resources of participants, agencies, and the community.

Adolescent↗
PubMed2001

Incentive compatible environmental regulation.

Optimal environmental regulations are derived in the presence of asymmetric information about pollution abatement costs. It is recognized that compliance may have to be induced through appropriate monitoring and enforcement measures. The regulator commits to monitoring of compliance with the incentive compatible environmental regulations, and asymmetric information characterizes the interaction between the firm and regulator. The probabilities of monitoring abatement standards and corresponding subsidies are optimally chosen to ensure firm compliance. Enforcement considerations are shown to distort downward the pollution abatement requirements mandated for firms.

Conservation of Natural Resources↗
PubMed1998

Clinical response of salaried consultants to economic incentives.

Several studies have found a relation between economic incentives and physicians' clinical decisions. The bulk of these studies deals with data from private organisations providing medical care. The purpose of the present study is to explore whether a similar relationship is valid in a system where hospital care is provided by salaried physicians in the public sector. A distinction is made between medical and economic prioritysetting. If the relative fees influence the proportion of outpatient surgery or the compositions of treatments, economic prioritysetting is said to take place. Data were collected from a sample of Norwegian hospitals. The main findings of the empirical section can be summarised in two points: (i) Economic prioritysetting seems to be applied in the choice between inpatient and outpatient surgical treatment for patients with an identical diagnosis. (ii) Medical priority setting seems to be applied in the priority among patients with different diagnoses.

Ambulatory Surgical Procedures↗
PubMed1988

Motivating safety belt use at a community hospital: an effective integration of incentive and commitment strategies.

An effective hospital-based safety-belt program incorporated several advantages over prior attempts to increase safety belt use, including (a) the use of indigenous staff as program sponsors, coordinators, and delivery agents; (b) a yearlong program evaluation; and (c) a combination of extrinsic incentives and intrinsic commitment. To be eligible for a weekly $5, employees met the following contingencies: (a) signed a pledge card; (b) displayed the signed pledge card in their vehicle; and (c) wore a safety belt. Overall, belt use increased from a 2-week baseline mean of 15.6% to 34.7% during the 6-month intervention, and decreased to 25.6% at withdrawal. For the pledge card signers (n = 188) and the nonsigners (n = 533), belt use increased from baseline means of 29.4% and 11.8% to intervention use rates of 75.1 and 17.7%, respectively. Withdrawal and 4-month follow-up use rates were 56.0% and 44.9% for the Pledge group, and 17.2% and 22.1% for the Nonpledge group.

Adult↗
PubMed1984

Can economic incentives explain the recent population movements to nonmetropolitan areas?

Factors affecting migration from metropolitan to nonmetropolitan areas of the United States are explored using a time-series model of annual net migration in Minnesota for the period 1951 to 1978. The importance of economic factors is emphasized. The authors "also found support for the null hypothesis of exogeneity of nonmetropolitan unemployment, the economic influence on migration that is most likely to be endogenous. The results of Chow Tests indicate that changes in the portion of migration behavior...investigated reflect stable responses to changes in economic incentives."

Americas↗
PubMed1977

Intermittent positive pressure breathing (IPPB) versus incentive spirometer (IS) therapy in the postoperative period.

The increase of the inflationary lung volume created by a respiratory maneuver is critical for preventing postoperative alveolar collapse. We measured this volume as achieved with IPPB or incentive spirometry (IS) in 20 postoperative surgical patients. Using IPPB, with gas flow and peak airway pressures carefully adjusted for each patient, a value of 2240 +/- 630 cc (mean +/- 1 SD) was obtained compared to 1960 +/- 650 cc with IS. This difference is highly significant (p less than 0.0005 by the Wilcoxon test). We conclude that IPPB, by careful application, and with monitoring of tidal volumes, is likely to provide better prophylaxis of postoperative pulmonary complications, particularly in patients with compromised lung function and in an intensive care unit, where enough trained personel are available.

Adult↗
PubMed2004

Dissociation of wanting and liking for alcohol in humans: a test of the incentive-sensitisation theory.

RATIONALE: Incentive sensitisation theory (IST) claims that the mechanism of reward is comprised of separate neurobiological systems of wanting and liking, that dependent drug use occurs as a result of sensitisation of the system controlling wanting, and that the two systems can be dissociated. OBJECTIVE: To test the IST prediction that wanting and liking for alcohol can be dissociated in humans. METHODS: Measures of wanting and liking for alcohol were obtained in three experiments. Experiment 1 examined whether liking for alcohol was associated with levels of wanting, as indexed by self-reported weekly alcohol intake. Experiments 2 and 3 also assessed the association between liking and wanting but in these experiments wanting was also indexed by alcohol consumption in the laboratory. Experiment 2 increased wanting for alcohol using an alcohol priming dose to determine whether liking would be similarly affected. Experiment 3 reduced liking for alcohol by adulterating drinks with Tween to see whether wanting would also be reduced. RESULTS: Little evidence for an association between liking and wanting for alcohol was found in Experiments 1-3 but, collapsing across all experiments, a weak positive correlation between liking and wanting was found. However, in Experiment 2, wanting was increased by the alcohol priming dose whereas liking was not and in Experiment 3 liking was reduced without a concurrent reduction in wanting. CONCLUSIONS: Although correlations between wanting and liking can be observed these results support the contention of the IST that wanting and liking for alcohol can be dissociated in human participants.

Adaptation, Physiological↗