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The Affordable Care Act encourages workplace wellness programs, chiefly by promoting programs that reward employees for changing health-related behavior or improving measurable health outcomes. Recognizing the risk that unhealthy employees might be punished rather than helped by such programs, the act also forbids health-based discrimination. We reviewed results of randomized controlled trials and identified challenges for workplace wellness programs to function as the act intends. For example, research results raise doubts that employees with health risk factors, such as obesity and tobacco use, spend more on medical care than others. Such groups may not be especially promising targets for financial incentives meant to save costs through health improvement. Although there may be other valid reasons, beyond lowering costs, to institute workplace wellness programs, we found little evidence that such programs can easily save costs through health improvement without being discriminatory. Our evidence suggests that savings to employers may come from cost shifting, with the most vulnerable employees-those from lower socioeconomic strata with the most health risks-probably bearing greater costs that in effect subsidize their healthier colleagues. [PUBLICATION ABSTRACT]

To assess adherence to and individual or systematic deviations from predicted physician compensation by gender or race/ethnicity at a large academic medical center that uses a salary-only structured compensation model incorporating national benchmarks and clear standardized pay steps and increments. All permanent staff physicians employed at Mayo Clinic medical practices in Minnesota, Arizona, and Florida who served in clinical roles as of January 2017. Each physician's pay, demographics, specialty, full-time equivalent status, benchmark pay for the specialty, leadership role(s), and other factors that may influence compensation within the plan were collected and analyzed. For each individual, the natural log of pay was used to determine predicted pay and 95% CI based on the structured compensation plan, compared with their actual salary. Among 2845 physicians (861 women, 722 nonwhites), pay equity was affirmed in 96% (n=2730). Of the 80 physicians (2.8%) with higher and 35 (1.2%) with lower than predicted pay, there was no interaction with gender or race/ethnicity. More men (31.4%; 623 of 1984) than women (15.9%; 137 of 861) held or had held a compensable leadership position. More men (34.7%; 688 of 1984) than women (20.5%; 177 of 861) were represented in the most highly compensated specialties. A structured compensation model was successfully applied to all physicians at a multisite large academic medical system and resulted in pay equity. However, achieving overall gender pay equality will only be fully realized when women achieve parity in the ranks of the most highly compensated specialties and in leadership roles.

Objective To evaluate the effects of Quality and Outcomes Framework (QOF) incentivised case finding for depression on diagnosis and treatment in targeted and non-targeted long-term conditions. Design Interrupted time series analysis. Setting General practices in Leeds, UK. Participants 65 (58%) of 112 general practices shared data on 37 229 patients with diabetes and coronary heart disease targeted by case finding incentives, and 101 008 patients with four other long-term conditions not targeted (hypertension, epilepsy, chronic obstructive pulmonary disease and asthma). Intervention Incentivised case finding for depression using two standard screening questions. Main outcome measures Clinical codes indicating new depression-related diagnoses and new prescriptions of antidepressants. We extracted routinely recorded data from February 2002 through April 2012. The number of new diagnoses and prescriptions for those on registers was modelled with a binomial regression, which provided the strength of associations between time periods and their rates. Results New diagnoses of depression increased from 21 to 94/100 000 per month in targeted patients between the periods 2002–2004 and 2007–2011 (OR 2.09; 1.92 to 2.27). The rate increased from 27 to 77/100 000 per month in non-targeted patients (OR 1.53; 1.46 to 1.62). The slopes in prescribing for both groups flattened to zero immediately after QOF was introduced but before incentivised case finding (p<0.01 for both). Antidepressant prescribing in targeted patients returned to the pre-QOF secular upward trend (Wald test for equivalence of slope, z=0.73, p=0.47); the slope was less steep for non-targeted patients (z=−4.14, p<0.01). Conclusions Incentivised case finding increased new depression-related diagnoses. The establishment of QOF disrupted rising trends in new prescriptions of antidepressants, which resumed following the introduction of incentivised case finding. Prescribing trends are of concern given that they may include people with mild-to-moderate depression unlikely to respond to such treatment.

Understanding how doctors respond to occupational and monetary incentives in health care payment systems is important for determining the effectiveness of such systems. This study examined changes in doctors' behaviors in response to monetary incentives within health care payment systems in a ceteris paribus setting. An online experiment was developed to analyze the effect of monetary incentives similar to fee-for-service (FFS) and capitation (CAP) on doctors' prescription patterns. In the first session, no monetary values were presented. In the second session conducted 1 week later, doctors were randomly assigned to one of two monetary incentive groups (FFS group: n = 25, CAP group: n = 25). In all sessions, doctors were presented with 10 cases and asked to determine the type and number of treatments. In the first session with no monetary incentives, there was no significant difference between the FFS and CAP groups in the number of treatments. When monetary incentives were provided, doctors in the CAP group prescribed fewer treatments than the FFS group. The perceived severity of the cases did not change significantly between sessions and between groups. linear mixed-effects regression model indicated the treatment choices were influenced by monetary incentives, but not by the perceived severity of the patient's symptoms. The monetary values incentivized the doctors' treatment choices, but not their professional evaluation of patients. Monetary values designed within health care systems influence the doctor's decisions in the form of external rewards, in addition to occupational values, and can thus be adjusted by more effective incentives.

Purpose This paper aims to examine how the use of environmental, social and governance (ESG) incentives intersects with top management power and various corporate governance mechanisms to affect excess annual cash bonus compensation. Design/methodology/approach The authors use a novel artificial intelligence (AI) technique to obtain data about ESG incentives use by firms in the S&P 500. The authors test the hypotheses with an endogenous treatment-regression and a contrast test. Findings When the top management team has power and uses ESG incentives, there is a 32% reduction in excess annual cash bonuses implying ESG incentives are an effective corporate governance tool. However, nuanced analyses reveal that when powerful management teams with ESG incentives are from environmentally sensitive industries, have a corporate social responsibility (CSR) committee or have long-term view institutional shareholders, they derive excess bonuses. Practical implications Stakeholders will better understand management’s motivations for the inclusion of ESG incentives in executive compensation contracts and be able to identify situations which require closer scrutiny. Social implications Given the increased popularity of ESG incentives, society, regulators, boards of directors and management teams will be interested in better understanding when these incentives might be effective and when they might be abused. Originality/value To the best of the authors’ knowledge, this study is the first to examine the use of ESG incentives in relation to excess pay. The authors contribute to both the CSR and executive compensation literatures. The work also uses a new methodological technique using AI to gather difficult-to-obtain data, opening new avenues for research.

Objectives One of the factors linked to South Africa’s relatively high maternal mortality ratio is late utilization of antenatal care (ANC). Early utilization is especially important in South Africa due to the high HIV prevalence amongst pregnant women. This study examined the impact of a package intervention, consisting of an incentive called the Thula Baba Box (TBB) and a community health worker (CHW) programme, on early utilization of ANC. Methods A pilot randomised controlled trial consisting of 72 women aged 18 and older was conducted in an urban area in South Africa to evaluate the impact of the package intervention. Women were recruited and randomised into either intervention (n = 39) or control group (n = 33). The intervention group received both the TBB and monthly CHW visits, while the control group followed standard clinical practice. Both groups were interviewed at recruitment and once again after giving birth. The outcomes measured are the timing of first ANC visit and whether they attended more than four times. It is anticipated that the box will also have a beneficial impact on infant health outcomes, but these fall out of the scope of this study. Results Women in the intervention groups sought care on average 1.35 months earlier than the control group. They were also significantly more likely to attend at least four antenatal clinic visits. Conclusions for practice Given the South African context and the importance of early care-seeking behaviour to improve health outcomes of HIV-positive pregnant women, the intervention can help to improve maternal and neonatal health outcomes. Further research is needed to investigate the impact of the two interventions separately, and to see if these findings hold in other communities.

In 2004, the United Kingdom invested $3.2 billion in a new program to reward general practitioners for the delivery of high-quality care. The authors examine longitudinal data on quality and report that the incentive program may have prompted a modest improvement in the quality of care for two of the three chronic conditions they studied. In 2004, the United Kingdom invested $3.2 billion in a new program to reward general practitioners for the delivery of high-quality care. The authors report that the incentive program may have prompted a modest improvement in the quality of care. In 2004, the United Kingdom committed £1.8 billion ($3.2 billion) to a new pay-for-performance contract for family practitioners. 1 During the first year, the levels of achievement exceeded those anticipated by the government, with an average of 83.4% of the available incentive payments claimed. 2 However, the quality of care in English family practices had already begun to improve in response to a wide range of initiatives, 3 – 6 including national standards for the treatment of major chronic diseases and a national system of inspection (Table 1). Family practitioners already had some experience with financial incentives from the limited use of incentive programs . . .

BACKGROUND Patient experience measures are central to many pay-for-performance (P4P) programs nationally, but the effect of performance-based financial incentives on improving patient care experiences has not been assessed. METHODS The study uses Clinician & Group CAHPS data from commercially insured adult patients (n = 124,021) who had visits with 1,444 primary care physicians from 25 California medical groups between 2003 and 2006. Medical directors were interviewed to assess the magnitude and nature of financial incentives directed at individual physicians and the patient experience improvement activities adopted by groups. Multilevel regression models were used to assess the relationship between performance change on patient care experience measures and medical group characteristics, financial incentives, and performance improvement activities. RESULTS Over the course of the study period, physicians improved performance on the physician-patient communication (0.62 point annual increase, p < 0.001), care coordination (0.48 point annual increase, p < 0.001), and office staff interaction (0.22 point annual increase, p = 0.02) measures. Physicians with lower baseline performance on patient experience measures experienced larger improvements (p < 0.001). Greater emphasis on clinical quality and patient experience criteria in individual physician incentive formulas was associated with larger improvements on the care coordination (p < 0.01) and office staff interaction (p < 0.01) measures. By contrast, greater emphasis on productivity and efficiency criteria was associated with declines in performance on the physician communication (p < 0.01) and office staff interaction (p < 0.001) composites. CONCLUSIONS In the context of statewide measurement, reporting, and performance-based financial incentives, patient care experiences significantly improved. In order to promote patient-centered care in pay for performance and public reporting programs, the mechanisms by which program features influence performance improvement should be clarified.

Expanding the use of interoperable electronic health record (EHR) systems to improve health care delivery is a national policy priority. We used the 2010-12 National Ambulatory Medical Care Survey-Electronic Health Records Survey to examine which physicians in what types of practices are implementing the systems, and how they are using them. We found that 72 percent of physicians had adopted some type of system and that 40 percent had adopted capabilities required for a basic EHR system. The highest relative increases in adoption were among physicians with historically low adoption levels, including older physicians and those working in solo practices or community health centers. As of 2012, physicians in rural areas had higher rates of adoption than those in large urban areas, and physicians in counties with high rates of poverty had rates of adoption comparable to those in areas with less poverty. However, small practices continued to lag behind larger practices. Finally, the majority of physicians who adopted the EHR capabilities required to obtain federal financial incentives used the capabilities routinely, with few differences across physician groups. [PUBLICATION ABSTRACT]

Paying health care providers to meet quality goals is an idea with widespread appeal, given the common perception that quality of care in the United States remains unacceptably low despite a decade of benchmarking and public reporting. There has been little critical analysis of the design of the current generation of quality incentive programs. In this paper we examine public reports of paying for quality over the past five years and assess each of the identified programs in terms of key design features, including the market share of payers, the structure of the reward system, the amount of revenue at stake, and the targeted domains of health care quality. [PUBLICATION ABSTRACT]