Current Diabetes Reports

, Volume 13, Issue 2, pp 188–195 | Cite as

Provider and Patient Directed Financial Incentives to Improve Care and Outcomes for Patients with Diabetes

  • Ilona S. Lorincz
  • Brittany C. T. Lawson
  • Judith A. LongEmail author
Health Care Delivery Systems in Diabetes (D Wexler, Section Editor)


Incentive programs directed at both providers and patients have become increasingly widespread. Pay-for-performance (P4P) where providers receive financial incentives to carry out specific care or improve clinical outcomes has been widely implemented. The existing literature indicates they probably spur initial gains which then level off or partially revert if incentives are withdrawn. The literature also indicates that process measures are easier to influence through P4P programs but that intermediate outcomes such as glucose, blood pressure, and cholesterol control are harder to influence, and the long-term impact of P4P programs on health is largely unknown. Programs directed at patients show greater promise as a means to influence patient behavior and intermediate outcomes such as weight loss; however, the evidence for long-term effects are lacking. In combination, both patient and provider incentives are potentially powerful tools but whether they are cost-effective has yet to be determined.


Diabetes mellitus Reimbursement Incentives Pay for performance Economics Behavioral 



Conflicts of interest: I.S. Lorincz: none; B.C.T. Lawson: none; J.A. Long: has received grant support from NIDDK.


Papers of particular interest, published recently, have been highlighted as • Of importance •• Of major importance

  1. 1.
    •• Loewenstein G, Brennan T, Volpp KG. Asymmetric paternalism to improve health behaviors. JAMA. 2007;298:2415–7. A good description of how behavioral economics can be used to help improve health behaviors.PubMedCrossRefGoogle Scholar
  2. 2.
    Johnson EJ, Goldstein D. Do defaults save lives? Sci Justice. 2003;302:1338–9.Google Scholar
  3. 3.
    Thaler RH, Mullainathan S. Behavioral economics. The Concise Encyclopedia of Economics. 2008. Available at: Accessed October 10, 2012.
  4. 4.
    Bell CM, Levinson W. Pay for performance: learning about quality. CMAJ. 2007;176:1717–9.PubMedGoogle Scholar
  5. 5.
    Epstein AM. Paying for performance in the United States and abroad. N Engl J Med. 2006;355:406–8.PubMedCrossRefGoogle Scholar
  6. 6.
    Longo DR, Schubert SL. Issues in pay for performance: the case of diabetes self-management. J Health Care Finance. 2006;33:17–23.PubMedGoogle Scholar
  7. 7.
    •• Scott A, Sivey P, Ait Ouakrim D, et al. The effect of financial incentives on the quality of health care provided by primary care physicians. Cochrane Database of Syst Rev. 2011;9:CD008451. This Cochrane Review evaluates the impact of different financial interventions on the quality of care delivered by primary care physicians (PCPs). A total of 7 rigorously-designed studies published between 2000–2009 were evaluated; all studies were randomized controlled trials (RCTs), controlled before and after studies (CBA), or interrupted time series analyses (ITS). Three of the studies included diabetes specific metrics.Google Scholar
  8. 8.
    •• Campbell S, Reeves D, Kontopantelis E, et al. Quality of primary care in England with the introduction of pay for performance. N Engl J Med. 2007;357:181–90. A comprehensive evalaution of England's program including diabetic specific outcomes.PubMedCrossRefGoogle Scholar
  9. 9.
    NHS website. Available at: Accessed October 2, 2012.
  10. 10.
    Doran T, Fullwood C, Gravelle H, et al. Pay-for-performance programs in family practices in the United Kingdom. N Engl J Med. 2006;355:375–84.PubMedCrossRefGoogle Scholar
  11. 11.
    Quality and outcomes framework for 2012/13. Available at: Accessed October 2, 2012.
  12. 12.
    Campbell SM, Roland MO, Middleton E, Reeves D. Improvements in quality of clinical care in english general practice 1998–2003: longitudinal observational study. BMJ. 2005;331:1121.PubMedCrossRefGoogle Scholar
  13. 13.
    • Vaghela P, Ashwort M, Schofield P, Gulliford MC. Population intermediate outcomes of diabetes under pay-for-performance incentives in England from 2004 to 2008. Diabetes Care. 2009;32:427–9. An evaluation of diabetes-specific outcome metrics for 98 % of all English family practices. There was an improvement in all metrics after the initiation of QOF; however, data was only analyzed from 2004–2007, limiting the analysis.PubMedCrossRefGoogle Scholar
  14. 14.
    Hippisley-Cox J, Vinogradova Y, Coupland C. Time series analysis for selected clinical indicators from the quality and outcomes framework 2001-2006’, final report for the information centre, version 1.1, R22 HSCIC (2007). Available at: Accessed October 2, 2012.
  15. 15.
    Hamilton FL, Bottle A, Vamos EP, et al. Impact of a pay-for-performance incentive scheme on age, sex, and socioeconomic disparities in diabetes management in UK primary care. J Ambul Care Manag. 2010;33:336–49.Google Scholar
  16. 16.
    Crawley D, Ng A, Mainous AG, Majeed A, Millett C. Impact of pay for performance on quality of chronic disease management by social class group in England. JR Soc Med. 2009;102:103–7.CrossRefGoogle Scholar
  17. 17.
    Millett C, Gray J, Saxena S, et al. Ethnic disparities in diabetes management and pay-for-performance in the UK: the Wandsworth prospective diabetes study. PLoS Med. 2007;4:e191.PubMedCrossRefGoogle Scholar
  18. 18.
    Millett C, Bottle A, Ng A, et al. Pay for perfomance and the quality of diabetes management in individuals with and without co-morbid medical conditions. JR Soc Med. 2009;102:369–77.CrossRefGoogle Scholar
  19. 19.
    Whyte S, Penny C, Phelan M, Hippisley-Cox J, Majeed A. Quality of diabetes care in patients with schizophrenia and bipolar disorder: Cross-sectional study. Diabet Med. 2007;24:1442–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Rosenthal MB, Landon BE, Normand SL, Frank RG, Epstein AM. Pay for performance in commercial HMOs. N Engl J Med. 2006;355:1895–902.PubMedCrossRefGoogle Scholar
  21. 21.
    Terry K. Pay for performance. How fast is it spreading? Available at: Accessed October 2, 2012.
  22. 22.
    Levin-Scherz J, DeVita N, Timbie J. Impact of pay-for-performance contracts and network registry on diabetes and asthma hedis measures in an integrated delivery network. Med Care Res Rev. 2006;63(1 Suppl):14S–28.PubMedCrossRefGoogle Scholar
  23. 23.
    Claffey TF, Agostini JV, Collet EN, Reisman L, Krakauer R. Payer-provider collaboration in accountable care reduced use and improved quality in Maine medicare advantage plan. Heal Aff. 2012;31:2074–83.CrossRefGoogle Scholar
  24. 24.
    Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: From concept to practice. JAMA. 2005;294:1788–93.PubMedCrossRefGoogle Scholar
  25. 25.
    Chen JY, Tian H, Taira Juarez D, et al. The effect of a PPO pay-for-performance program on patients with diabetes. Am J Manag Care. 2010;16:e11–9.PubMedGoogle Scholar
  26. 26.
    Young G, Meterko M, Beckman H, et al. Effects of paying physicians based on their relative performance for quality. J Gen Intern Med. 2007;22:872–6.PubMedCrossRefGoogle Scholar
  27. 27.
    Coleman K, Reiter KL, Fulwiler D. The impact of pay-for-performance on diabetes care in a large network of community health centers. J Health Care Poor Underserved. 2007;18:966–83.PubMedCrossRefGoogle Scholar
  28. 28.
  29. 29.
    • Long JA, Jahnle EC, Richardson DM, Loewenstein G, Volpp KG. Peer mentoring and financial incentives to improve glucose control in African American veterans: A randomized trial. Ann Intern Med. 2012;156:416–24. Only published randomized control trial evaluating financial incentives to improve diabetic outcomes.PubMedGoogle Scholar
  30. 30.
    Austin S, Wolfe BL. The effect of patient reminders and gas station gift cards on patient adherence to testing guidelines for diabetes. WMJ. 2011;110:132–7.PubMedGoogle Scholar
  31. 31.
    Raiff BR, Dallery J. Internet-based contingency management to improve adherence with blood glucose testing recommendations for teens with type 1 diabetes. J Appl Behav Anal. 2010;43:487–91.PubMedCrossRefGoogle Scholar
  32. 32.
    Cafazzo JA, Casselman M, Hamming N, Katzman DK, Palmert MR. Design of an mHealth app for the self-management of adolescent type 1 diabetes: a pilot study. J Med Internet Res. 2012;14:e70.Google Scholar
  33. 33.
    Schauer PR, Kashyap SR, Wolski K, et al. Bariatric surgery vs intensive medical therapy in obese patients with diabetes. New Engl J Med. 2012;366:1567–76.PubMedCrossRefGoogle Scholar
  34. 34.
    Chen L, Magliano DJ, Zimmet PZ. The worldwide epidemiology of type 2 diabetes mellitus– present and future perspectives. Nat Rev Endocrinol. 2012;8:228–36.CrossRefGoogle Scholar
  35. 35.
    Mingrone G, Panunzi S, De Gaetano A, Guidone C, Iaconelli A, Leccesi L, et al. Bariatric surgery vs conventional medical therapy for type 2 diabetes. New Engl J Med. 2012;366:1577–85.PubMedCrossRefGoogle Scholar
  36. 36.
    •• Volpp KG, John L, Troxel AB, et al. Financial incentive-based approaches for weight loss: a randomized trial. JAMA. 2008;300:2631–7. A randomized control trial of 2 different incentive structures both of which led to greater weight loss than usual care.PubMedCrossRefGoogle Scholar
  37. 37.
    Kullgren JT, Loewenstein G, Troxel AB, et al. A randomized controlled trial of financial incentives to promote weight loss among obese employees: Presented at the Society of General Internal Medicine 2012 National Meeting, Orlando, FL.Google Scholar
  38. 38.
    Jeffery RW, Drewnowski A, Epstein LH, et al. Long-term maintenance of weight loss: current status. Health Psychol. 2000;19(1 Suppl):5–16.PubMedCrossRefGoogle Scholar
  39. 39.
    Elfhag K, Rössner S. Who succeeds in maintaining weight loss? A conceptual review of factors associated with weight loss maintenance and weight regain. Obes Rev. 2005;6:67–85.PubMedCrossRefGoogle Scholar
  40. 40.
    Roland M. Linking physicians’ pay to the quality of care– a major experiment in the United Kindgrom. N Engl J Med. 2004;351:1448–54.PubMedCrossRefGoogle Scholar
  41. 41.
    • Halpern SD, Madison KM, Volpp KG. Patients as mercenaries? The ethics of using financial incentives in the war on unhealthy behaviors. Circ Cardiovasc Qual Outcomes. 2009;2:514–6. A good discussion of the ethical concerns raised by fiancial incentives for patients.PubMedCrossRefGoogle Scholar
  42. 42.
    Mitnick S, Snyder L, Hood VL. America College of Physicians Ethics, Professionalism and Human Rights Committee 2010 Position Paper. Ethical considerations for the use of patient incentives to promote personal responsibility for health: West Virginia medicaid and beyond. Available at: Accessed October 2nd, 2012.
  43. 43.
    Lester H, Schmittdiel J, Selby J, et al. The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of 4 Kaiser Permanente indicators. BMJ. 2010;340:c1898.PubMedCrossRefGoogle Scholar
  44. 44.
    Bishop G, Brodkey AC. Personal responsibility and physician responsibility–West Virginia's medicaid plan. N Engl J Med. 2006;355:756–8.PubMedCrossRefGoogle Scholar
  45. 45.
    Shaw J. Is it acceptable for people to be paid to adhere to medication? No. BMJ. 2007;335:233.PubMedCrossRefGoogle Scholar
  46. 46.
    Sunstein CA, Thaler RH. Libertarian paternalism is not an oxymoron. Chic Law Rev. 2003;70:1159–202.CrossRefGoogle Scholar
  47. 47.
    Long JA, Helweg-Larsen M, Volpp KG. Patient opinions regarding 'pay for performance for patients'. J Gen Intern Med. 2008;23:1647–52.PubMedCrossRefGoogle Scholar
  48. 48.
    Pearson SD, Lieber SR. Financial penalties for the unhealthy? Ethical guidelines for holding employees responsible for their health. Heal Aff. 2009;28:845–52.CrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York (outside the USA) 2012

Authors and Affiliations

  • Ilona S. Lorincz
    • 1
  • Brittany C. T. Lawson
    • 2
  • Judith A. Long
    • 2
    • 3
    • 4
    Email author
  1. 1.Department of Medicine, Endocrine DivisionUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaUSA
  2. 2.Department of Medicine, Division of General Internal MedicineUniversity of Pennsylvania Perelman School of MedicinePhiladelphiaUSA
  3. 3.Philadelphia VA Center for Health Equity Research and PromotionPhiladelphiaUSA
  4. 4.University of Pennsylvania Leonard Davis Institute of Health EconomicsPhiladelphiaUSA

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