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Concept: Incentive


Background Spending and quality under global budgets remain unknown beyond 2 years. We evaluated spending and quality measures during the first 4 years of the Blue Cross Blue Shield of Massachusetts Alternative Quality Contract (AQC). Methods We compared spending and quality among enrollees whose physician organizations entered the AQC from 2009 through 2012 with those among persons in control states. We studied spending changes according to year, category of service, site of care, experience managing risk contracts, and price versus utilization. We evaluated process and outcome quality. Results In the 2009 AQC cohort, medical spending on claims grew an average of $62.21 per enrollee per quarter less than it did in the control cohort over the 4-year period (P<0.001). This amount is equivalent to a 6.8% savings when calculated as a proportion of the average post-AQC spending level in the 2009 AQC cohort. Analogously, the 2010, 2011, and 2012 cohorts had average savings of 8.8% (P<0.001), 9.1% (P<0.001), and 5.8% (P=0.04), respectively, by the end of 2012. Claims savings were concentrated in the outpatient-facility setting and in procedures, imaging, and tests, explained by both reduced prices and reduced utilization. Claims savings were exceeded by incentive payments to providers during the period from 2009 through 2011 but exceeded incentive payments in 2012, generating net savings. Improvements in quality among AQC cohorts generally exceeded those seen elsewhere in New England and nationally. Conclusions As compared with similar populations in other states, Massachusetts AQC enrollees had lower spending growth and generally greater quality improvements after 4 years. Although other factors in Massachusetts may have contributed, particularly in the later part of the study period, global budget contracts with quality incentives may encourage changes in practice patterns that help reduce spending and improve quality. (Funded by the Commonwealth Fund and others.).

Concepts: Budget, Health care in the United States, Massachusetts, Edward Harkness, Incentive, Commonwealth Fund, Health care, Blue Cross and Blue Shield Association


US fruit and vegetable (FV) intake remains below recommendations, particularly for low-income populations. Evidence on effectiveness of rebates in addressing this shortfall is limited.

Concepts: Incentive, Malnutrition, Epidemiology, Vegetable, Nutrition, Randomized controlled trial


Purpose . We aimed to understand how employer characteristics relate to the use of incentives to promote participation in wellness programs and to explore the relationship between incentive type and participation rates. Design . A cross-sectional analysis of nationally representative survey data combined with an administrative business database was employed. Settings/Subjects . Random sampling of U.S. companies within strata based on industry and number of employees was used to determine a final sample of 3000 companies. Of these, 19% returned completed surveys. Measures . The survey asked about employee participation rate, incentive type, and gender composition of employees. Incentive types included any incentives, high-value rewards, and rewards plus penalties. Analysis . Logistic regressions of incentive type on employer characteristics were used to determine what types of employers are more likely to offer which type of incentives. A generalized linear model of participation rate was used to determine the relationship between incentive type and participation. Results . Employers located in the Northeast were 5 to 10 times more likely to offer incentives. Employers with a large number of employees, particularly female employees, were up to 1.25 times more likely to use penalties. Penalty and high-value incentives were associated with participation rates of 68% and 52%, respectively. Conclusion . Industry or regional characteristics are likely determinants of incentive use for wellness programs. Penalties appear to be effective, but attention should be paid to what types of employees they affect.

Concepts: Type, Incentive, Opinion poll, Official statistics, Regression analysis, Logistic regression, Sampling, Employment


Timely follow-up after hospital discharge may decrease readmission to hospital. Financial incentives to improve follow-up have been introduced in the United States and Canada, but it is unknown whether they are effective. Our objective was to evaluate the impact of an incentive program on timely physician follow-up after hospital discharge.

Concepts: Motivation, Surgeon, Physician, Travel incentive, Incentive program, Time series, United States, Incentive


Employers commonly use adjustments to health insurance premiums as incentives to encourage healthy behavior, but the effectiveness of those adjustments is controversial. We gave 197 obese participants in a workplace wellness program a weight loss goal equivalent to 5 percent of their baseline weight. They were randomly assigned to a control arm, with no financial incentive for achieving the goal, or to one of three intervention arms offering an incentive valued at $550. Two intervention arms used health insurance premium adjustments, beginning the following year (delayed) or in the first pay period after achieving the goal (immediate). A third arm used a daily lottery incentive separate from premiums. At twelve months there were no statistically significant differences in mean weight change either between the control group (whose members had a mean gain of 0.1 pound) and any of the incentive groups (delayed premium adjustment, -1.2 pound; immediate premium adjustment, -1.4 pound; daily lottery incentive, -1.0 pound) or among the intervention groups. The apparent failure of the incentives to promote weight loss suggests that employers that encourage weight reduction through workplace wellness programs should test alternatives to the conventional premium adjustment approach by using alternative incentive designs, larger incentives, or both.

Concepts: Health insurance, Medicine, Weight, Statistics, Incentive, Statistical significance, Health, Nutrition


It is not known whether large financial incentives enhance long-term smoking cessation rates outside clinical or workplace settings.

Concepts: Smoking, Nicotine, Incentive, Smoking cessation


We assess the additional forest cover protected by 13 rural communities located in the southern state of Chiapas, Mexico, as a result of the economic incentives received through the country’s national program of payments for biodiversity conservation. We use spatially explicit data at the intra-community level to define a credible counterfactual of conservation outcomes. We use covariate-matching specifications associated with spatially explicit variables and difference-in-difference estimators to determine the treatment effect. We estimate that the additional conservation represents between 12 and 14.7 percent of forest area enrolled in the program in comparison to control areas. Despite this high degree of additionality, we also observe lack of compliance in some plots participating in the PES program. This lack of compliance casts doubt on the ability of payments alone to guarantee long-term additionality in context of high deforestation rates, even with an augmented program budget or extension of participation to communities not yet enrolled.

Concepts: World Forestry Congress, Effectiveness, Incentive, Agriculture, Conservation biology, Ecology, Biodiversity, Deforestation


There is no evidence comparing head-to-head the effects of monetary incentives to act and to abstain from acting on behaviour. We present an experiment, conducted between June and September 2012, that directly compares the effects of those two different monetary incentive schemes on eating behaviour: we evaluate incentives to eat against incentives not to eat. A large number of participants (n = 353) had bowls of sweets next to them while they watched different videos over two experimental sessions that were two days apart. Sweets eating was monitored and monetary incentives to eat or not to eat were introduced during one of the videos for participants randomly allocated to these conditions. Our results show that, while both types of incentives were effective in changing sweets-eating behaviour when they were in place, only incentives not to eat had significant carryover effects after they were removed. Those effects were still significant two days after the monetary incentives had been eliminated. We also present some additional results on personality and health-related variables that shed further light on these effects. Overall, our study shows that incentives not to eat can be more effective in producing carryover effects on behaviour in domains like the one explored here.

Concepts: Acting, Experiment, Incentive, Eating


A randomized controlled trial ‘Money for Medication’(M4M) was conducted in which patients were offered financial incentives for taking antipsychotic depot medication. This study assessed the attitudes and ethical considerations of patients and clinicians who participated in this trial.

Concepts: Hospital, Incentive, Pharmacology, Randomized controlled trial


Community health workers (CHWs) are increasingly recognized as an integral component of the health workforce needed to achieve public health goals in low- and middle-income countries (LMICs). Many factors influence CHW performance. A systematic review was conducted to identify intervention design related factors influencing performance of CHWs. We systematically searched six databases for quantitative and qualitative studies that included CHWs working in promotional, preventive or curative primary health services in LMICs. One hundred and forty studies met the inclusion criteria, were quality assessed and double read to extract data relevant to the design of CHW programmes. A preliminary framework containing factors influencing CHW performance and characteristics of CHW performance (such as motivation and competencies) guided the literature search and review. A mix of financial and non-financial incentives, predictable for the CHWs, was found to be an effective strategy to enhance performance, especially of those CHWs with multiple tasks. Performance-based financial incentives sometimes resulted in neglect of unpaid tasks. Intervention designs which involved frequent supervision and continuous training led to better CHW performance in certain settings. Supervision and training were often mentioned as facilitating factors, but few studies tested which approach worked best or how these were best implemented. Embedment of CHWs in community and health systems was found to diminish workload and increase CHW credibility. Clearly defined CHW roles and introduction of clear processes for communication among different levels of the health system could strengthen CHW performance. When designing community-based health programmes, factors that increased CHW performance in comparable settings should be taken into account. Additional intervention research to develop a better evidence base for the most effective training and supervision mechanisms and qualitative research to inform policymakers in development of CHW interventions are needed.

Concepts: Primary health care, Incentive, Qualitative research, Healthcare, Public health, Health care, Health economics, Medicine