The effects of financial incentives for prescribers

This review is the first update of the Cochrane review of the effects of different financial policies seeking to influence prescriber behaviour. Researchers at The Cochrane Collaboration searched for all studies that could answer this question and found 18 studies. Their findings are summarised below.

What are financial incentives for prescribers?

Large amounts of healthcare funds are spent on medicines, and these amounts are increasing. Increased spending on medicines could mean less money for other healthcare or non-healthcare services. Health insurers and policy-makers are therefore looking for ways to ensure better use of medicines and to control the costs of medicines while still ensuring that patients get the medicines they need.

One way to try to control medicine spending is to influence the people who prescribe medicines, for instance, through financial incentives. One way of doing this involves introducing a budget cap or a budget target. Here, doctors and healthcare organisations are given a budget and the responsibility of staying within this budget. Another approach is to enforce a pay for performance policy, whereby doctors or their organisations are financially rewarded or punished for their prescribing behaviour. A third approach is to apply a reimbursement rate policy. Here, the amount of money doctors are reimbursed for medicine prescriptions is reduced, making the prescription of medicines less financially attractive to doctors.

These policies may lead doctors to prescribe fewer or cheaper medicines. This may reduce the use of unnecessary medicines but may also lead to poorer health outcomes.

What happens when financial incentives for prescribers are introduced?

Pharmaceutical budget caps or targets:

- This policy may lead to a modest reduction in overall drug use per patient (low-certainty evidence).

- We are uncertain of the effects of this policy on drug costs or on healthcare utilisation, as the certainty of the evidence has been assessed as very low.

- The effects of this policy on health outcomes have not been measured.

Pay for performance policies:

- We are uncertain of the effects of these policies on drug use or health outcomes, as the certainty of the evidence has been assessed as very low.

- The effects of this policy on drug costs or on healthcare utilisation have not been measured.

Reimbursement rate policies:

- We are uncertain about the effects of reimbursement rate policies because the quality of the evidence has been assessed as very low.

How up-to-date is this review?

The review authors searched for studies that had been published up to January 2015.

Authors' conclusions: 

Although financial incentives are considered an important element in strategies to change prescribing patterns, limited evidence of their effects can be found. Effects of policies, including pay for performance policies, in improving quality of care and health outcomes remain uncertain. Because pharmaceutical policies have uncertain effects, and because they might cause harm as well as benefit, proper evaluation of these policies is needed. Future studies should consider the impact of these policies on health outcomes, drug use and overall healthcare expenditures, as well as on drug expenditures.

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Background: 

The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories. Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care. Financial incentives seeking to influence prescribers' behaviour include budgetary arrangements at primary care and hospital settings (pharmaceutical budget caps or targets), financial rewards for target behaviours or outcomes (pay for performance interventions) and reduced benefit margin for prescribers based on medicine sales and prescriptions (pharmaceutical reimbursement rate reduction policies). This is the first update of the original version of this review.

Objectives: 

To determine the effects of pharmaceutical policies using financial incentives to influence prescribers' practices on drug use, healthcare utilisation, health outcomes and costs (expenditures).

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (searched 29/01/2015); MEDLINE, Ovid SP (searched 29/01/2015); EMBASE, Ovid SP (searched 29/01/2015); International Network for Rational Use of Drugs (INRUD) Bibliography (searched 29/01/2015); National Health Service (NHS) Economic Evaluation Database (searched 29/01/2015); EconLit - ProQuest (searched 02/02/2015); and Science Citation Index and Social Sciences Citation Index, Institute for Scientific Information (ISI) Web of Knowledge (citation search for included studies searched 10/02/2015). We screened the reference lists of relevant reports and contacted study authors and organisations to identify additional studies.

Selection criteria: 

We included policies that intend to affect prescribing by means of financial incentives for prescribers. Included in this category are pharmaceutical budget caps or targets, pay for performance and drug reimbursement rate reductions and other financial policies, if they were specifically targeted at prescribing or drug utilisation. Policies in this review were defined as laws, rules, regulations and financial and administrative orders made or implemented by payers such as national or local governments, non-government organisations, private or social insurers and insurance-like organisations. One of the following outcomes had to be reported: drug use, healthcare utilisation, health outcomes or costs. The study had to be a randomised or non-randomised trial, an interrupted time series (ITS) analysis, a repeated measures study or a controlled before-after (CBA) study.

Data collection and analysis: 

At least two review authors independently assessed eligibility for inclusion of studies and risks of bias using Cochrane Effective Practice and Organisation of Care (EPOC) criteria and extracted data from the included studies. For CBA studies, we reported relative effects (e.g. adjusted relative change). The review team re-analysed all ITS results. When possible, the review team also re-analysed CBA data as ITS data.

Main results: 

Eighteen evaluations (six new studies) of pharmaceutical policies from six high-income countries met our inclusion criteria. Fourteen studies evaluated pharmaceutical budget policies in the UK (nine studies), two in Germany and Ireland and one each in Sweden and Taiwan. Three studies assessed pay for performance policies in the UK (two) and the Netherlands (one). One study from Taiwan assessed a reimbursement rate reduction policy. ITS analyses had some limitations. All CBA studies had serious limitations. No study from low-income or middle-income countries met the inclusion criteria.

Pharmaceutical budgets may lead to a modest reduction in drug use (median relative change -2.8%; low-certainty evidence). We are uncertain of the effects of the policy on drug costs or healthcare utilisation, as the certainty of such evidence has been assessed as very low. Effects of this policy on health outcomes were not reported. Effects of pay for performance policies on drug use and health outcomes are uncertain, as the certainty of such evidence has been assessed as very low. Effects of this policy on drug costs and healthcare utilisation have not been measured. Effects of the reimbursement rate reduction policy on drug use and drug costs are uncertain, as the certainty of such evidence has been assessed as very low. No included study assessed the effects of this policy on healthcare utilisation or health outcomes. Administration costs of the policies were not reported in any of the included studies.

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