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PubMed2006

Realigning clinical and economic incentives to support depression management within a medicaid population: the Colorado access experience.

The authors describe their experiences in developing an economically sustainable depression care management program within Colorado Access, a non-profit Medicaid health plan. They describe high rates of mental health issues, medical comorbidities, and psychosocial barriers to care within the plan's Medicaid population. They discuss how the company redirected resources to incorporate depression care management into an intensive care management program focused on high-cost members with multiple chronic medical conditions. This strategy allowed Colorado Access to cost effectively care manage a targeted group of high-cost Medicaid recipients across multiple primary care physician (PCP) practices without requiring changes in provider workflow.

Colorado↗
PubMed1985

Promoting weight control at the worksite: a pilot program of self-motivation using payroll-based incentives.

Thirty-six individuals participated in a worksite weight-loss program in which the central component was a self-motivation program of biweekly payroll deductions refunded contingent on meeting self-selected weight-loss goals. Half were assigned to early treatment and the remainder to a delayed treatment control group. Nine additional individuals also enrolled at the time of delayed treatment and were included in descriptive analyses of factors associated with weight loss. Results showed low program attrition over 6 months (6%) and mean weight losses (12.3 lb) that are competitive with those obtained in clinical settings. Although not different at baseline, participants in the delayed treatment group lost more than twice as much weight as those in the early treatment condition. This difference was interpreted as either a strong seasonal effect or a critical mass effect related to the proportion of employees at the worksite participating in the program. We conclude that self-motivation programs for health behavior change using the payroll system as an organization framework offer a promising new methodology for promoting healthful behaviors in work settings.

Adult↗
PubMed1991

Minding our Ps and Qs? Financial incentives for efficient hospital behaviour.

In this paper, the empirical evidence addressing the particular issue of how hospitals may be reimbursed is reviewed. Most forthcoming is the indeterminate effect of prospective payment systems using diagnosis-related groups as a means of controlling costs. Such systems, by controlling only the price of hospital care, remain vulnerable to compensatory increase in patient throughput, cost-shifting and patient-shifting despite hospital cost per case being reduced. Health maintenance organisations have been shown to reduce hospital costs, but their effects on patients selection and patient outcome are unclear. Selective contracting in California (similar to the U.K. Government's proposed internal market) has also been shown to reduce costs by affecting both the price and quantity of hospital care. But these effects have occurred only in areas with high concentrations of hospitals. Global and clinical budgeting (which control price times quantity) seem to offer the most potential for cost reduction whilst maintaining patient outcome. By monitoring both cost and outcome within clinical budgets it should be possible to reduce wasteful variations in health care and so establish more efficient hospital practice.

Australia↗
PubMed2005

The effect of financial incentives on gatekeeping doctors: evidence from a natural experiment.

In many health care systems generalist physicians act as gatekeepers to secondary care. Under the English fundholding scheme from 1991/1992 to 1998/1999 general practices could elect to be given a budget to meet the costs of certain types of elective surgery (chargeable electives) for their patients and could retain any surplus. They did not pay for non-chargeable electives or for emergency admissions. Non-fundholding practices did not bear the cost of any type of hospital admissions. Fundholding is to be reintroduced from April 2005. We estimate the effect of fundholding using a differences in differences methodology on a large 4-year panel of English general practices before and after the abolition of fundholding. The abolition of fundholding increased ex-fundholders' admission rates for chargeable elective admissions by between 3.5 and 5.1%. The effect on the early wave fundholders was greater (around 8%) than on later wave fundholders. We also use differences in differences for two types of admissions (non-chargeable electives, emergencies) not covered by fundholding as additional controls for unobserved temporal factors. These differences in differences in differences estimates suggest that the abolition of fundholding increased ex-fundholders' chargeable elective admissions by 4.9% (using the non-chargeables DID) and by 3.5% (using the emergencies DID).

Algorithms↗
PubMed2004

Incentives and pharmaceutical reimbursement reforms in Spain.

The aim of this paper is to assess whether cost containment has been affected by recent pharmaceutical reimbursement reforms that have been introduced in the Spanish health care system over the period 1996-2002, under the conservative Popular Party Government. Four main reimbursement policies can be observed in the Spanish pharmaceutical market after 1996, each of them largely unintegrated with the other three. First, a second supplementary negative list of excluded pharmaceutical products was introduced in 1998. Second, a reference pricing (RP) system was introduced in December 2000, with annual updating and enlargement. Third, the pharmacies' payment system has moved from the traditional set margin on the consumer price to a margin that varies according to the consumer price of the product, the generic status of the product, and the volume of sales by pharmacies. And fourth, general agreements between the government and the industry have been reached with cost containment objectives. In the final section of this paper, we present an overall assessment of the impact of these pharmaceutical reimbursement policies on the behaviour of the agents in the pharmaceutical market.

Cost Sharing↗
PubMed2003

Day treatment for cocaine dependence: incremental utility over outpatient counseling and voucher incentives.

Urban, poor, crack cocaine-dependent clients were randomly assigned to outpatient addiction counseling (n=39) or day treatment (n=40). Participants in both conditions received equivalent individual cognitive-behavioral counseling and earned equivalent payment vouchers for providing cocaine-negative urine samples. However, day treatment participants attended significantly more psychoeducational and recreational groups and received two meals per day. Prior to random assignment, more participants expressed a preference for day treatment and participants were more likely to return for an initial appointment following assignment to day treatment. However, no significant between-groups differences in tenure or abstinence were detected during the 3-month course of treatment. These null findings were attributable to an absence of a dose-response effect for the group interventions in the day treatment condition. In addition, there may have been a ceiling effect from the vouchers, which masked the influence of the additional day treatment components.

Adult↗