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PubMed2004

To err on humans is not benign. Incentives for adoption of medical error-reporting systems.

Concerns about frequent and harmful medical errors have led policy makers to advocate the creation of a system for medical error reporting. Health providers, fearing that reported information about errors would be used against them under the current medical malpractice system, have been reluctant to participate in such reporting systems. We propose a re-design of the malpractice system -- one in which penalties are a function of the health provider's reporting efforts -- to overcome this incentive problem. We also consider some alternatives to this mechanism that address two important ways in which reporting effort may not be observable: hospitals may have interests distinct from individual physicians and may not be able to observe their reporting efforts, and a regulatory agency or a court may not be able to adequately observe reporting efforts by a provider.

Health Personnel↗
PubMed2005

Glucocorticoids dose-dependently remodel energy stores and amplify incentive relativity effects.

To test whether glucocorticoids amplify incentive motivation, three groups of rats were adrenalectomized and replaced subcutaneously with pellets of corticosterone (B), containing 0, 30, or 80% B and cholesterol. A fourth group of sham adrenalectomized rats received cholesterol pellets. Animals were placed on a four-arm maze baited with 32% sucrose for 5-min daily sessions. After 7 days of minimal drinking on the maze at free-feeding weights, their body weights were gradually reduced to 90% of their free-feeding weights for the next 12 days (pre-shift phase). The sucrose concentration was reduced to 4% for the next 2 days (post-shift phase). B dose-dependently increased 32% sucrose intake, insulin secretion, and relative fat depots. Intake was reduced similarly in all groups following the shift to 4%, resulting in a relative B-dependent intake suppression following the shift to 4%. Videoscoring of locomotor activity indicated that search behaviors were not different between groups prior to the shift to 4%, whereas the increase in search behavior following the shift to 4% sucrose was entirely B-dependent. These data were predicted by a new model of chronic stress positing two regulatory axes on brain by glucocorticoids: one indirect axis by which glucocorticoids remodel energy stores to provide metabolic feedback and a direct axis whereby glucocorticoids act directly on brain to remodel appetitive structure.

Adaptation, Physiological↗
PubMed2006

Market incentives, human lives, and AIDS vaccines.

For many, an AIDS vaccine holds the promise of intervening in a widespread epidemic because it is not predicated on changing economic structures and social contexts underlying vulnerability to HIV for millions of individuals. Yet 20 years into the AIDS epidemic, there is still no vaccine. Based on interviews of AIDS vaccine researchers, watchdog organizations, and ethics groups from the United States, South Africa, and Kenya conducted between August and December of 2003, this paper explores possible answers to the question of why there is no vaccine, looking in particular at contradictions between a biomedical research industry increasingly driven by market incentives and a disease that primarily affects individuals living in low-income countries with little vaccine purchasing power. Producing a vaccine that could be effective in low-income regions requires new kinds of initiatives that can coordinate research nationally and globally, and circumvent current regulatory mechanisms that dictate against the development and dissemination of low-profit medical technologies. Until such initiatives are supported, however, vaccine research will continue at a devastatingly slow pace at the cost of millions of lives annually.

AIDS Vaccines↗
PubMed2006

Parallel incentive processing: an integrated view of amygdala function.

The amygdala is a heterogeneous structure that has been implicated in a wide variety of functions, most notably in fear conditioning. From this research, an influential serial model of amygdala processes has emerged in which aversive learning is mediated by the amygdala basolateral nucleus whereas performance, in this case of various defensive reflexes, is mediated by the central nucleus. By contrast, recent evidence from appetitive conditioning studies suggests that the basolateral and central nuclei operate in parallel to mediate distinct incentive processes: the basolateral nucleus encodes emotional events with reference to their particular sensory-specific features, whereas the central nucleus encodes their more general motivational or affective significance. Given that there is little if any direct behavioral evidence for the serial model, we suggest that more attention should be given to the claims of the parallel view.

Amygdala↗
PubMed2004

Developing treatments for inborn errors: incentives available to the clinician.

Disorders resulting from inborn errors of metabolism (IEM) affect very small numbers of individuals. The entire population, however, of patients suffering the results of inherited metabolic disorders is large, and has been of increasing concern to patient groups and health care professionals in the United States as well as other countries throughout the world. The 1983 US Orphan Drug Act (ODA) serves to facilitate the development of drugs to treat rare diseases by providing several economic incentives. The sponsor of a product designated as an orphan by the Food & Drugs Administration (FDA) Office of Orphan Products Development (OPD) qualifies for tax credits on clinical trial expenses, the award of grant funding by FDA, through the OPD, and 7 years of marketing exclusivity for a designated drug, or biological product that receives FDA market approval. Orphan drug legislation in the US has benefited victims of IEM by encouraging development of drugs for metabolic deficiencies affecting populations that otherwise would be ignored. America's solution to the orphan drug problem has had worldwide impact. The success of this legislation was a factor leading to the 1993 orphan drug law in Japan; the 1997 implementation of a process whereby most FDA-approved orphan drugs and biological products will be similarly approved in Australia; and, in 1999, regulation on orphan medicinal products in the European Union (EU). Today, international support for rare disease research is providing stimulus and motivation to overcome the financial barriers and encourage development of treatment for very rare diseases throughout the world.

Humans↗
PubMed2002

Enduring effects of environmental enrichment on novelty seeking, saccharin and ethanol intake in two rat lines (RHA/Verh and RLA/Verh) differing in incentive-seeking behavior.

The Roman high- and low-avoidance (RHA/Verh and RLA/Verh) rat lines represent, respectively, low emotional/anxious and high novelty seeker vs. high emotional/anxious and low novelty seeker profiles. In the present study, RLA/Verh and RHA/Verh rats, either reared in pairs from weaning (untreated) or reared in groups of 8-10 in an enriched environment until the age of 7 months, were tested for exploratory and novelty-seeking behavior in the hole board (including novel objects under the holes), as well as for their preference for saccharin-water and ethanol-water in a two-bottle free-choice paradigm. Testing started when rats were 20 months old in order to study the long-lasting effects of differential rearing. RHA/Verh rats explored more and showed greater preference for (and intake of) saccharin as well as for ethanol than RLA/Verh rats, thus confirming their validity as a rat model for sensation/reward seeking. Environmental enrichment (EE) increased head-dipping behavior (i.e., novelty seeking) in both rat lines, without affecting locomotor activity. EE treatment increased the preference for, and volume intake of, saccharin (especially at the higher concentrations tested) in the relatively low saccharin-preferring RLA/Verh rats, and also enhanced ethanol consumption in both rat lines. Thus, the results demonstrate consistent and enduring effects of EE on incentive-seeking behavior and further the analysis of how individual differential predispositions for the need of novelty and contact with (or consumption of) rewarding substances arise through either biological (genetic) or early environmental factors, or both.

Alcohol Drinking↗
PubMed1990

Integrating practice guidelines with financial incentives.

Practice guidelines, in whatever form, hold significant implications for the delivery and the financing of health care. Hence, great care must be taken in developing them. They must be scientifically sound and thus defensible. They must incorporate clinical perspectives and consider patients' preferences. They must cover appropriate as well as inappropriate services. They must foster creation and adoption of a rational payment system. What guidelines, in their best form, can do is enable physicians, faced with an overwhelming array of often conflicting information, to reduce some of the uncertainty they must cope with and to practice the most clinically effective medicine. For physicians to do so requires valid information from a credible source, most often in conjunction with appropriate financial incentives.

Clinical Protocols↗
PubMed1999

Isolation changes the incentive value of sucrose and social behaviour in juvenile and adult rats.

The present study was undertaken to assess the motivational aspects of social behaviour in juvenile and adult rats using the conditioned place preference (CPP) test and anticipatory behaviour for social contact. In addition, the consequences of social isolation during different periods of age on the motivational properties of sucrose-drinking and adult social behaviour were studied. Social play and adult social contact could be used as incentives for place preference conditioning and for inducing conditioned hyperactivity (anticipation) in rats. Both social activities have motivational properties for individually housed rats, whereas group-housing dramatically reduced the motivational aspects of adult social contact. In contrast, sucrose-drinking appears to have motivational aspects independent of the housing condition. Adult social behaviour could not induce a CPP in juvenile isolated rats, suggesting that juvenile isolation during 4 5 weeks reduced the motivational aspects of adult social contact. It seems likely that no CPP was established as a result of the reduced level of social behaviour during the conditioning sessions. Additionally, juvenile isolation during 4-5 weeks appeared to also decrease the motivational properties of sucrose-drinking in maturity, because the intensity of anticipation in response to sucrose was significantly suppressed. Thus, the data suggest that juvenile isolation during 4-5 weeks decreases the motivational properties of both social contact and sucrose-drinking in later life.

Aging↗
PubMed2000

Previous exposure to amphetamine increases incentive to obtain the drug: long-lasting effects revealed by the progressive ratio schedule.

The present experiment tested whether previous exposure to amphetamine would enhance rats' predisposition to self-administer a high dose of the drug under fixed (FR) and progressive ratio (PR) schedules of reinforcement. Rats in different groups were given five injections of either amphetamine (1.5 mg/kg, i.p.) or saline (1.0 ml/kg, i.p.), one injection administered every third day and, starting 10 days later, given the opportunity to lever press for amphetamine (200 microg/kg/infusion, i.v.) on each of several 4 h sessions. When allowed to self-administer up to 10 infusions under first an FR-1 and then an FR-2 schedule, amphetamine and saline pre-exposed rats were indistinguishable and readily acquired the lever press response. However, when tested under the PR schedule of reinforcement, rats previously exposed to amphetamine achieved higher break points than saline pre-exposed rats across six consecutive PR sessions. This difference between groups was long lasting and durable. When compared to saline pre-exposed rats on three separate tests conducted 10, 14 and 21 days following the last PR session, rats pre-exposed to amphetamine also showed (i) greater nucleus accumbens dopamine reactivity to amphetamine (1.0 mg/kg, i.p.), (ii) higher break points when retested on the PR schedule, and (iii) a greater locomotor response to amphetamine (1.0 mg/kg, i.p.). On the last test, both groups showed higher levels of locomotion than no drug control animals that received amphetamine for the first time on this test. These findings suggest that previous exposure to amphetamine produces a long lasting enhancement in the incentive motivation animals will exhibit in their effort to obtain the drug. This enhancement appears to parallel sensitization of the drug's locomotor and nucleus accumbens dopamine activating effects. It may very well be exacerbated by continued exposure to self-administered amphetamine.

Amphetamine↗
PubMed2000

Quality incentives in a regulated market with imperfect information and switching costs: capitation in general practice.

We model a system akin to the British National Health Service (NHS), in which general practictioners (GPs) are paid by capitation from general taxation. GPs are horizontally and vertically differentiated and compete for patients via their imperfect observed quality. We show that for any given capitation fee quality is lower and the incentive effects of the fee on quality are smaller when there is imperfect information. There are diminishing welfare gains from improving patient information but increasing welfare gains from reducing switching costs. GPs do not act efficiently to improve patient information via advertising or to reduce the costs of switching.

Capitation Fee↗
PubMed2000

The economics of managed care in behavioral health. Basic concepts and incentives.

Psychiatrists and other behavioral health clinicians must accept managed care philosophy because it is not going to disappear. A keen understanding of the specific issues that are pertinent to the managed care contracts that are signed is important if the clinician is to serve as an effective advocate for his or her patients on a case by case basis. Managed care in behavioral health services is now preparing to enter a new phase in development in which there will be reduced competition amongst the BHMCOs because the number of managed care organizations are decreasing with mergers and acquisitions. These adjustments in the market will leave the clinician and the provider organization potentially less able to make changes in their own delivery systems unless the discussions and strategies for change are structured in such a way that the incentives for all involved parties are aligned. Stakeholders in the process of managing care for behavioral health will need to come together to educate all parties about the value of necessary behavioral health treatment at the point of need. Appropriate access to all necessary behavioral health services could create additional short-term costs, but with reasonable management of the services, these costs could be kept in line.

Behavior Therapy↗
PubMed2002

Market reforms and public incentives: finding a balance in the Republic of Macedonia.

The Republic of Macedonia is undertaking sweeping reforms of its health sector. Funded by a World Bank credit, the reforms seek to improve the efficiency and quality of primary health care (PHC) by significantly strengthening the role of the market in health care provision. On the supply-side, one of the key reform proposals is to implement a capitation payment system for PHC physicians. By placing individual physicians on productivity-based contracts, these reforms will effectively marketize all PHC provision. In addition, the Ministry of Health is considering the sale or concessions of public PHC clinics to private groups, indicating the government's commitment to marketization of health care provision. Macedonia is in a unique position to develop a new role for the private sector in PHC provision. The private provision of outpatient care was legalized soon after independence in 1991; private physicians now account for nearly 10% of all physicians and 22% of PHC physicians. If the reforms are fully realized, all PHC physicians-over 40% of all physicians-will be financially responsible for their clinical practices. This study draws on Macedonia's experience with limited development of private outpatient care starting in 1991 and the reform proposals for PHC, finding a network of policies and procedures throughout the health sector that negatively impact private and public sector provision. An assessment of the effects that this greater policy environment has on private sector provision identifies opportunities to strategically enhance the reforms. With respect to established market economies, the study finds justification for a greater role for government intervention in private health markets in transition economies. In addition to micro-level payment incentives and administrative controls, marketization in Central and Eastern Europe requires an examination of insurance contracting procedures, quality assurance practices, public clinic ownership, referral practices, hospital privileges, and capital investment policies.

Capitalism↗
PubMedDate not supplied

Childhood immunizations: a parent education and incentive program.

This article describes some strategies to help reduce the immunization barriers of parental knowledge deficits and transportation costs through a parent education and incentive program. A record review of 471 children in 22 licensed Norfolk, Virginia, day-care centers revealed that 141 (29.9%) had inadequate age-appropriate immunizations. Educational programs included depictions of preventable communicable diseases and their consequences. Upon completion of appropriate immunizations, parents received transportation vouchers and gifts. By June 2000, 255 parents, day-care administrators, teachers, and staff had participated in educational programs and seven day-care centers earned certificate awards for improved immunization rates among enrollees. Four centers had 100% age-appropriate immunization rate, and three had a rate of 92% to 95%.

Child↗
PubMed1997

Respiratory sinus arrhythmia versus neck/trapezius EMG and incentive inspirometry biofeedback for asthma: a pilot study.

This pilot study compared biofeedback to increase respiratory sinus arrhythmia (RSA) with EMG and incentive inspirometry biofeedback in asthmatic adults. A three-group design (Waiting List Control n = 5, RSA biofeedback n = 6, and EMG biofeedback n = 6) was used. Six sessions of training were given in each of the biofeedback groups. In each of three testing sessions, five min. of respiratory resistance and EKG were obtained before and after a 20-min biofeedback session. Additional five-min epochs of data were collected at the beginning and end of the biofeedback period (or, in the control group, self-relaxation). Decreases in respiratory impedance occurred only in the RSA biofeedback group. Traub-Hering-Mayer (THM) waves (.03-.12 Hz) in heart period increased significantly in amplitude during RSA biofeedback. Subjects did not report significantly more relaxation during EMG or RSA biofeedback than during the control condition. However, decreases in pulmonary impedance, across groups, were associated with increases in relaxation. The results are consistent with Vaschillo's theory that RSA biofeedback exercises homeostatic autonomic reflex mechanisms through increasing the amplitude of cardiac oscillations. However, deep breathing during RSA biofeedback is a possible alternate explanation.

Adolescent↗
PubMed1992

Contingent take-home incentive: effects on drug use of methadone maintenance patients.

This study examined contingent methadone take-home privileges for effectiveness in reducing on-going supplemental drug use of methadone maintenance patients. Fifty-three new intakes were randomly assigned to begin receiving take-home privileges after 2 consecutive weeks of drug-free urines or to a noncontingent procedure in which take-homes were delivered independently of urine test results. The contingent procedure produced more individuals with at least 4 consecutive weeks of abstinence (32% vs. 8%); 28% of noncontingent subjects also achieved abstinence after shifting to the contingent procedure. Lower baseline rate of drug-free urines was strongly associated with successful outcome, whereas the type of drug abused (cocaine vs. benzodiazepines) did not influence outcomes. Findings support a recommendation for using contingent take-home incentives to motivate abstinence during methadone maintenance treatment.

Adult↗
PubMed1998

Use of personal trainers and financial incentives to increase exercise in a behavioral weight-loss program.

Exercise is the best predictor of long-term weight loss. This study evaluated two strategies for improving exercise adherence and long-term weight loss in obese outpatients. Obese men and women (N = 193) were randomized to 1 of 5 treatment groups for 18 months: standard behavior therapy (SBT); SBT with supervised walks (SW) 3 times per week; SBT + SW with personal trainers (PT), who walked with participants, made phone reminders, and did make-up SW; SBT + SW with monetary incentives (I) for completing SW; and SBT + SW + PT + I. Both PT and I enhanced attendance at SWs, the combination producing the best adherence. Increased walk attendance did not result in higher overall energy expenditure, however, and long-term weight loss was also not improved. Post hoc analyses suggest that the level of exercise needed for successful long-term weight loss is much higher than that usually recommended in behavioral treatment programs.

Adult↗
PubMed2000

Responsiveness to threats and incentives, expectancy of recurrence, and distress and disengagement: moderator effects in women with early stage breast cancer.

Models of neurobiological systems linking personality, motivation, and emotion can be integrated with the expectancy construct to suggest hypotheses about distress and giving up in response to adversity. In 220 women with breast cancer, threat responsiveness-sensitivity of the behavioral inhibition system (BIS)-and incentive responsiveness-sensitivity of the behavioral activation system (BAS)-and expectancies about cancer recurrence were measured. It was predicted and found that high BIS sensitivity interacted with recurrence expectancy to predict elevated distress and disengagement. Low BAS sensitivity (reward responsiveness) also interacted with expectancy of recurrence to predict elevated disengagement. In contrast, high BAS sensitivity (fun seeking) interacted with recurrence expectancy to predict elevated distress. Discussion centers on theoretical implications and possible applications.

Adaptation, Psychological↗
PubMed1984

Choking under pressure: self-consciousness and paradoxical effects of incentives on skillful performance.

Choking under pressure is defined as performance decrements under circumstances that increase the importance of good or improved performance. A model for choking on coordination and skill tasks is proposed, holding that the pressure increases the conscious attention to the performer's own process of performance and that this increased conscious attention disrupts the automatic or overlearned nature of the execution. Six experiments provided data consistent with this model. Three studies showed that increased attention to one's own process of performance resulted in performance decrements. Three other studies showed similar decrements produced by situational manipulations of pressure (i.e., implicit competition, a cash incentive, and audience-induced pressure). Individuals low in dispositional self-consciousness were shown to be more susceptible to choking under pressure than those high in it.

Achievement↗