SUPPORT Summaries
Evidence of the effects of health system interventions
for low- and middle-income countries
Evidence of the effects of health system interventions
for low- and middle-income countries
February, 2017 - SUPPORT Summary of a systematic review | print this article | download PDF
The use of financial incentives to directly reward performance and quality has been proposed as a strategy to improve the quality of care provided by primary care physicians. An increasing number of countries, like the USA and UK, use financial incentives.
People making decisions concerning the use of financial incentives to improve the quality of healthcare provided by primary care physicians
Scott A, Sivey P, Ait Ouakrim D, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane database Syst Rev 2011 (9): CD008451.
A summary of studies addressing a clearly formulated question that uses systematic and explicit methods to identify, select, and critically appraise the relevant research, and to collect and analyse data from the included studies.
SUPPORT – was an international project to support the use of policy relevant reviews and trials to inform decisions about maternal and child health in low- and middle-income countries, funded by the European Commission (FP6) and the Canadian Institutes of Health Research.
Avariety of methods can be used to pay primary care physicians. Payments can be made in exchange for different outputs, including: working for a specified time period (salary), providing specific services (fee for service), providing care for a specific population (capitation), or providing a pre specified level of quality of care (pay for performance). Payments can also be unconditional, for each additional output, or they can be conditional on reaching a threshold or target. Payments can also be prospective (providing a fixed budget) or retrospective. With retrospective payments, there may or may not be a cap.
The level of payment for primary physicians can also vary in several ways. The level can be fixed in advance, physicians can have varying degrees of discretion as to the amount of money they can charge, and the amount of payment can be reduced or withheld if physicians do not comply with what is required (financial penalties). The amount of payment can also vary depending on administrative rules (e.g. depending on qualifications of the physicians, where they practice, or the types of patients they see).
Changes in any of these characteristics of how physicians are paid or the level of payment alters their financial incentives. If physicians respond to these changes in incentives, it can affect the quality of the care that they provide.
| Review objectives: To examine the effect of changes in the method and level of payment on the quality of care provided by primary care physicians (PCPs). | ||
| Type of | What the review authors searched for | What the review authors found |
|---|---|---|
| Study designs & interventions | Randomised trials, controlled before after studies (CBA), and interrupted time series studies (ITS) evaluating the impact of changes in the method or level of payment for primary care physicians. |
7 studies, including: cluster randomised trials (3), CBA studies (2), ITS study (1), and controlled ITS study (1). The studies evaluated: single threshold target payments (3); a fixed fee per patient achieving a specified outcome(1); payments based on the relative ranking of medical groups’ performance (tournament based pay) (1); a mix of tournament based pay and threshold payments (1); and changing from a blended payments scheme to salaried payment (1). |
| Participants | Primary care physicians |
Five studies took place in large private health plans in the US; One study in 20 PCP medical groups in England; and one study in 82 medical practices in Germany. |
| Settings | Primary care |
The studies were from US (5), the UK (1), and Germany (1). |
| Outcomes | Quality of care was defined as patient reported outcome measures, clinical behaviours, and intermediate clinical and physiological measures. |
Studies examined: smoking cessation (3); patients’ assessment of the quality of care (1); cervical cancer screening, mammography screening, and HbA1 (2 studies, 1 of them also childhood immunisation, chlamydia screening, and appropriate asthma medication); and four outcomes in diabetes (1). |
| Date of most recent search: August 2009 | ||
| Limitations: This is a well conducted systematic review with only minor limitations. | ||
Scott A, Sivey P, Ait Ouakrim D, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane database Syst Rev 2011 (9): CD008451.
High: This research provides a very good indication of the likely effect. The likelihood that the effect will be substantially different† is low.
Moderate: This research provides a good indication of the likely effect. The likelihood that effect will be substantially different† is moderate.
Low: This research provides some indication of the likely effect. Howevver, the likelihood that it will be substantially different† is high.
Very low: This research does not provide a reliable indication of the likely effect. The likelihood that the effect will be substantially different† is very high.
* This is sometimes referred to as 'quality of evidence' or 'confidence in the estimate'.
† Substantially different = a large enough difference that it might affect a decision.
See last page for more information.
Seven studies were included in this review. Three of the studies evaluated single threshold target payments, one examined a fixed fee per patient achieving a specified outcome, one study evaluated payments based on the relative ranking of medical groups’ performance (tournament based pay), one study examined a mix of tournament based pay and threshold payments, and one study evaluated changing from a blended payments scheme to salaried payment. Six out of the seven studies used schemes that paid medical groups rather than individual physicians. For those studies that involved payments to medical groups, none reported how the payments were used or distributed within the medical group.
Outcome measures included targeted preventive interventions (support for smoking cessation, screening, immunizations) and management goals for chronic conditions (asthma and diabetes).
Six of the seven studies showed positive but modest effects on quality of care for some primary outcome measures, but not all. Physicians were able to select into or out of the incentive schemes or health plans and there was a high risk of bias in all of the studies.
The effects of financial incentives on the quality of health care provided by primary care physicians. |
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| People: Primary care physicians. Settings: Primary care in the US, UK, and Germany. Intervention: Different types of financial incentives (see above), mostly paid to medical groups rather than individuals. Comparison: Only three out of the seven studies described the payment scheme used in the control group or before the intervention occurred, and only two studies reported estimates of the size of payments as a percentage of total revenue. |
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| Outcomes |
Median difference* Interquartile range |
Certainty of the evidence (GRADE) |
Comments | |
|
Professional practice achievement of targeted goals for preventive interventions and management of chronic conditions |
1.7% 0.3 to 4.7% |
Very low† |
The apparent size of the effects were small and varied from 3.1% worse to 7.7% more achievement of desired practice. |
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GRADE: GRADE Working Group grades of evidence (see above and last page) The difference in achievement of targeted goals for physicians who received financial incentives compared to physicians who did receive the same financial incentives, adjusted for baseline differences in achievement of those goals in non-randomised studies. Calculated by the author of this Summary. † All seven studies had a high risk of bias and the effects were inconsistent. |
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| Findings | Interpretation* |
|---|---|
| APPLICABILITY | |
| The studies included in this systematic review were all from high income countries. |
The impacts of financial incentives for primary care physicians are likely to vary depending on clinical, demographic and organisational factors, as well as on the magnitude of the incentives and payment methods.
|
| EQUITY | |
| The systematic review did not report impacts on equity or disadvantaged populations. |
The impact of financial incentives on equity are uncertain and might depend on the design of the incentives.
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| ECONOMIC CONSIDERATIONS | |
| The systematic review did not report costs or cost effectiveness. |
The costs of financial incentives can be expected to increase with the level of the incentives, whereas any savings and impacts on the quality of care or with increasing levels of incentives are uncertain.
|
| MONITORING & EVALUATION | |
| The systematic review found only seven studies evaluating different incentives and measures of quality of care. All of the studies had a high risk of bias. |
The use of financial incentives to improve the quality of care provided by primary care physicians should be carefully designed and evaluated using randomised trials.
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*Judgements made by the authors of this summary, not necessarily those of the review authors, based on the findings of the review and consultation with researchers and policymakers in low-income countries. For additional details about how these judgements were made see: www.supportsummaries.org/methods |
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This systematic review assessed the effects of paying for performance on the provision of health care and health outcomes in low and middle income countries:
Witter S, Fretheim A, Kessy FL, et al. Paying for performance to improve the delivery of health interventions in low- and middle income countries. Cochrane Database syst Rev 2012 (2): CD007899.
These two systematic reviews assessed the effects of different methods of paying primary care physicians: Giuffrida A, Gosden T, Forland F, et al. Target payments in primary care: effects on professional practice and health care outcomes. Cochrane Database syst Rev 2000 (3): CD000531.
Gosden T, Forland F, Kristiansen IS, Sutton M, Leese B, Giuffrida A, et al. Capitation, salary, fee for service and mixed systems of payment: effects on the behaviour of primary care physicians. Cochrane Database syst Rev 2000 (3): CD002215.
Petersen LA, Woodard LD, Urech T, et al. Does pay for performance improve the quality of health care? Ann Intern Med 2006; 145(4): 265-72.
Houle SK, McAlister FA, Jackevicius CA, et al. Does performance based remuneration for individual health care practitioners affect patient care? A systematic review. Ann Intern Med 2012; 157(12): 889-99.
Chaix Couturier C, Durand Zaleski I, Jolly D, Durieux P. Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues. Int J Qual Health Care 2000; 12(2): 133-42.
Agustín Ciapponi and Sebastián García Martí, Argentine Cochrane Centre IECS Institute for Clinical Effectiveness and Health Policy, Argentina
None declared. For details, see: www.supportsummaries.org/coi
This summary has been peer reviewed by: Tony Scott and Yuan Beibei.
Scott A, Sivey P, Ait Ouakrim D, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane database Syst Rev 2011 (9): CD008451.
Ciapponi A, García Martí S. Do financial incentives improve the quality of healthcare provided by primary care physicians? A SUPPORT Summary of a systematic review. February 2017.
www.supportsummaries.org
All Summaries:
evidence informed health policy, evidence based, systematic review, health systems research, health care, low and middle income countries, developing countries, primary health care physician incentive plans, primary care physicians, quality of health care, financial incentives.
