Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues

Objective. To identify all financial incentives that had been proposed, des cribed, or used regardless of their initial objective and, when possible, t o assess the results of these incentives on costs, process or outcomes of c are. Material and methods. Systematic review of the literature. Databases search ed were: Medline, Embase, Health Planning and Administration, Pascal, Inter national Pharmaceutical Abstracts and the Cochrane Library. Search terms we re: health professionals and type of practice, type of incentive, methodolo gy, languages English or French,January 1993 to May 1999. Results. Financial incentives concerned the modalities of physician payment and financing of the health care system. Confounding factors included: age of the doctor, training, speciality, place and type of medical practice, p revious sanctions for over-prescribing, type and severity of disease, type of insurance. Risks of financial incentives were: limited access to certain types of care, lack of continuity of care, conflict of interests between t he physician and the patient. Any form of fund-holding or capitation decrea sed the total volume of prescriptions by 0-24%, and hospital days by up to 80% compared with fee-for-service. Annual cap on doctors' incomes resulted in referrals to colleagues when target income is reached. Discussion. Financial incentives can be used to reduce the use of health ca re resources, improve compliance with practice guidelines or achieve a gene ral health target. It may be effective to use incentives in combination dep ending on the target set for a given health care programme.