Evidence is poor that financial incentives in primary care improve patients’ wellbeing

Authors: Susan Mayor 

Publication date:  08 Sep 2011


Research evidence fails to show that providing financial incentives to primary care services improves patients’ wellbeing, concludes a Cochrane review published this week. The report warns policy makers to think carefully about the design of such programmes if they are to achieve real improvements for patients.

Anthony Scott, a professorial research fellow, and colleagues at the University of Melbourne’s Institute of Applied Economic and Social Research searched the literature for studies that assessed the effects of financial incentive schemes on the quality of care given by primary care practitioners. They looked for the degree to which changes in doctors’ behaviour improved patients’ wellbeing.

Despite hundreds of financial incentive schemes being introduced into primary care in the United States, Australia, the United Kingdom, and elsewhere they found only seven studies (from a total of nearly 3000) that met their criteria (Cochrane Database of Systematic Reviews 2011;9:CD008451, doi:10.1002/14651858.CD008451.pub2). Six of the seven studies showed modest improvements for some but not all primary outcome measures. One study showed no effect on quality of care.

Five of the studies took place in the US, looking at incentive schemes put in place by large private health insurance plans with the aim of improving the quality of care provided by the group practices with which they contracted. A UK study evaluated a salaried payment scheme to GPs, and a German study assessed payments to increase smoking cessation.

The schemes used a variety of payment mechanisms, including payments for reaching single thresholds, a fixed fee per patient achieving an outcome, payments based on the relative ranking of the group’s performance, and salary increases. Six of the seven studies used schemes that paid medical groups rather than individual doctors. The programmes looked at a wide range of health issues, including smoking cessation, cervical screening, mammography screening, diabetes care, childhood vaccination, and appropriate use of asthma treatment.

The reviewers found that the different financial incentive schemes had “modest and variable” effects on the quality of healthcare provided. Effects were found only in a minority of outcome measures. For example, the three studies on smoking cessation showed that financial incentives had significant effects on referral rates and on recording of patients’ smoking status but not on measures of patients’ smoking cessation.

Peter Sivey, a coauthor of the study, said, “Poor study design led to substantial risk of bias in most studies, and none of the studies addressed issues of selection bias as a result of the ability of primary care physicians to select into or out of the incentive scheme.”

The review concluded, “The use of financial incentives to reward primary care practitioners for improving the quality of primary healthcare services is growing. However, this is insufficient evidence to support or not support this.

“Implementation of financial incentive schemes should proceed with caution and be more carefully designed.”

Commenting on the findings, Clare Gerada, chairwoman of the Royal College of General Practitioners, said, “These incentives rapidly lose their value. We must caution against using incentives to affect behaviour and instead concentrate on allowing GPs the time, space, and capacity to do what they want to do—that is, to provide excellent, accessible, personal care to patients.”

She added, “What we should concentrate on is tapping into the natural desire of health professionals—GPs in particular—to do the right thing, because it is the right thing to do.”

Dr Gerada pointed out that Donald Berwick, administrator of the US Centers for Medicare and Medicaid Services, recently said, “I do not think that the way to get better doctoring and better nursing is to put money on the table in front of doctors and nurses . . . I think people respond to joy and work and love and achievement and learning and appreciation and gratitude and a sense of a job well done. I think that it feels good to be a good doctor and better to be a better doctor.”

Susan Mayor BMJ

Cite this as BMJ Careers ; doi: