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Feedback and financial incentives may not improve pediatric preventive care in Medicaid HMOs

Immunizations and other cost-effective preventive health services are underused by many poor children. Yet providing physicians in Medicaid managed care organizations (MCOs) with feedback on compliance with preventive health services, even with financial bonuses for compliance, does not increase their provision of these services, concludes a study supported by the Agency for Health Care Policy and Research (HS07634). These findings should not be interpreted to mean that financial incentives cannot capture physicians' attention regarding preventive care. Other factors may have contributed to the lack of effect, suggests Alan L. Hillman, M.D., M.B.A., of the University of Pennsylvania.

Dr. Hillman and his colleagues randomly assigned primary care sites serving children in a Medicaid HMO to one of three groups: a feedback group (physicians received written feedback about compliance scores), a feedback and financial incentive group (financial bonus when compliance criteria were met), and a control group. The researchers evaluated compliance with pediatric preventive care guidelines through semiannual chart audits conducted from 1993 to 1995.

All three study groups improved total compliance scores from 56 percent to 73 percent, as well as scores for immunizations (from 62 percent to 79 percent) and other preventive care (from 54 percent to 71 percent). However, there were no significant differences between either intervention group and the control group. Bonuses paid out over the course of the study amounted to an average of $2,000 per site, but they had little effect on an individual physician's overall income. This financial incentive may not have been sufficient to influence behavior, suggest the researchers. Also, only 56 percent of the 27 responding sites were aware of the feedback and incentive program, despite repeated mailings. Finally, during the course of the study, much public attention was focused on improving pediatric preventive care, and many HMOs conducted quality improvement activities. These system-wide events could have overshadowed the impact of the incentive during the short time it was offered.

Perhaps most important are the lessons from this research regarding the need to mimic reality as closely as possible when deciding on the magnitude of financial incentives, the need for physician "buy in" (perhaps related to the size of incentives), and the length of the intervention. However, these considerations must be balanced by the fact that actual clinical practice cannot be as highly controlled as it is in randomized controlled trials. Balancing control in health services research with the exigencies of actual practice will remain a challenge, concludes Dr. Hillman.

See "Pediatric preventive care incentives in a Medicaid HMO," by Dr. Hillman, Kimberly Ripley, M.A.S., Neil Goldfarb, B.S., and others, in Pediatrics 104, pp. 931-935, 1999.

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