The European Journal of Health Economics

, Volume 17, Issue 6, pp 723–732 | Cite as

The true impact of the French pay-for-performance program on physicians’ benzodiazepines prescription behavior

  • Audrey Michel-LepageEmail author
  • Bruno Ventelou
Original Paper



The French pay-for-performance (P4P) contract CAPI implemented by the national health insurance included a target-goal which aims at reducing benzodiazepines prescriptions. In this investigation, we would like to assess whether: (1) the general practitioners (GPs) having signed P4P contract obtain better results regarding the target-goal than non-signatories; (2) (part of) this progression is due to the CAPI contract itself (tentative measurement of a “causal effect”); (3) (part of) the money spent on this P4P incentive can be self-financed with the amount of pharmaceuticals saved.


We matched cross-sectional and longitudinal data including 4622 French GPs from June 2011 to December 2012. A treatment effect model using instrumental variables was performed to take into account potential self-selection issue in signing. After having identified the NET impact of the P4P, we calculate the cost of an avoided benzodiazepines treatment.


In our study, GPs who have signed the CAPI contract (36 % of the sample) are more numerous in achieving benzodiazepines target goal than non-signatories: 90.7 vs. 85.5 %. After controlling for the self-selection bias, the propensity of GPs to achieve the benzodiazepines target is only 0.31 % higher for signatories than for their non-signing counterparts—estimate for June 2012, which yields a statistically significant gap. Our economic analysis demonstrates that the CAPI contract does not allow savings, but presents in 2012 a NET cost of 93.6€ per avoided benzodiazepines treatment (291€ in 2011).


The P4P contract has a positive but modest impact on the achievement of GPs regarding benzodiazepines indicator.


Pay-for-performance CAPI Benzodiazepines General practitioners Behaviors 

JEL Classification




We thank the health care administration (Caisse Primaire d’Assurance Maladie) for having provided us the databases according to the CNIL authorization, and the Regional Health Agency (Agence Régionale de Santé) for having delivered us the anonymous identity of southeastern GPs.

A.M- L. received a PhD grant from the “Méditerranée Infection” foundation (a non-profit-making foundation, The authors benefit from the financial support of the Agence Nationale de Sécurité du Medicament et des produits de santé (ANSM) in the context of a research-platform in pharmacoepidemiology created in 2014. Warning: the content of this article commits only the authors and does not reflect necessarily the position of the health authority. None of the above bodies had any role in study design; the collection, analysis, and interpretation of data; the writing of the paper; or the decision to submit this paper for publication.

Compliance with ethical standards

Conflict of interest

The authors declare no conflicts of interest.


  1. 1.
    Or, Z.: P4P for generalists: first results. IRDES, France (2010)Google Scholar
  2. 2.
    Bras, P.-L.: Le contrat d’amélioration des pratiques individuelles (CAPI) à la lumière de l’expérience anglaise. J. Déconomie Médicale 29(5), 216–230 (2011)CrossRefGoogle Scholar
  3. 3.
    Roekeghem, F.V.: Pour une nouvelle dynamique collective de santé publique. Trib. Santé. no 35, 21–27 (2012)CrossRefGoogle Scholar
  4. 4.
    Polton, D., Aubert, J.-M.: Le contrat d’amélioration des pratiques individuelles, aboutissement ou nouveau départ pour la gestion des soins? (2010), Accessed Sept 2010
  5. 5.
    Saint-Lary, O., Plu, I., Naiditch, M.: Adhérer ou pas au CAPI : de quel clivage des généralistes le paiement à la performance est-il le révélateur ? Rev. Fr. Aff. Soc. no 2–3, 180–209 (2011)Google Scholar
  6. 6.
    Bras, P.-L., Duhamel, G.: Rémunérer les médecins selon leurs performances: les enseignements des expériences étrangères. Inspection générale des affaires sociales, Paris (2008)Google Scholar
  7. 7.
    Mannion, R., Davies, H.: Payment for performance in health care. BMJ 336, 306–308 (2008)CrossRefPubMedPubMedCentralGoogle Scholar
  8. 8.
    Hahn, J.: Pay-for-performance in health care. CRS report for congress. The Library of Congress, Washington (2006)Google Scholar
  9. 9.
    Doran, T., Fullwood, C., Gravelle, H., Reeves, D., Kontopantelis, E., Hiroeh, U., Roland, M.: Pay-for-performance programs in family practices in the United Kingdom. N. Engl. J. Med. 355, 375–384 (2006)CrossRefPubMedGoogle Scholar
  10. 10.
    Walker, S., Mason, A.R., Claxton, K., Cookson, R., Fenwick, E., Fleetcroft, R., Sculpher, M.: Value for money and the quality and outcomes framework in primary care in the UK NHS. Br. J. Gen. Pract. J. R. Coll. Gen. Pract. 60, e213–e220 (2010)CrossRefGoogle Scholar
  11. 11.
    Lindenauer, P.K., Remus, D., Roman, S., Rothberg, M.B., Benjamin, E.M., Ma, A., Bratzler, D.W.: Public reporting and pay for performance in hospital quality improvement. N. Engl. J. Med. 356, 486–496 (2007)CrossRefPubMedGoogle Scholar
  12. 12.
    ANSM: État des lieux de la consommation des benzodiazépines en France. Agence Nationale de Sécurité du Médicament (ANSM) (2013)Google Scholar
  13. 13.
    Insomnie, anxiété: consommation des benzodiazépines en hausse, Accessed 8 Jan 2014
  14. 14.
    Bernstein, D., Blotiere, P.-O., Bousquet, F., Legal, R., Silvera, L.: La variabilité des pratiques en médecine générale: une analyse sur données de l’Assurance-Maladie. CNAMTS (2012), Accessed 8 Aug 2015
  15. 15.
    Heckman, J., Ichimura, H., Smith, J., Todd, P.: Characterizing selection bias using experimental data. Econometrica. 66, 1017–1098 (1998)CrossRefGoogle Scholar
  16. 16.
    Angrist, J., Krueger, A.B.: Instrumental variables and the search for identification: from supply and demand to natural experiments. National Bureau of Economic Research, Cambridge (2001)CrossRefGoogle Scholar
  17. 17.
    Heckman, J.: Instrumental variables. A study of implicit behavioral assumptions used in making program evaluations. J. Hum. Resour. 32, 441–462 (1997)CrossRefGoogle Scholar
  18. 18.
    Alshamsan, R., Lee, J.T., Majeed, A., Netuveli, G., Millett, C.: Effect of a UK pay-for-performance program on ethnic disparities in diabetes outcomes: interrupted time series analysis. Ann. Fam. Med. 10, 228–234 (2012)CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Campbell, S.M., Reeves, D., Kontopantelis, E., Sibbald, B., Roland, M.: Effects of pay for performance on the quality of primary care in England. N. Engl. J. Med. 361, 368–378 (2009)CrossRefPubMedGoogle Scholar
  20. 20.
    Gravelle, H., Sutton, M., Ma, A.: Doctor behaviour under a pay-for-performance contract: treating, cheating and case finding?*. Econ. J. 120, F129–F156 (2010)CrossRefGoogle Scholar
  21. 21.
    Saint-Lary, O., Sicsic, J.: Impact of a pay-for-performance programme on French GPs’ consultation length. Health Policy Amst, Neth (2014)Google Scholar
  22. 22.
    Hsieh, H.-M., Tsai, S.-L., Shin, S.-J., Mau, L.-W., Chiu, H.-C.: Cost-effectiveness of diabetes pay-for-performance incentive designs. Med. Care 53, 106–115 (2015)CrossRefPubMedGoogle Scholar
  23. 23.
    Tan, E.C.-H., Pwu, R.-F., Chen, D.-R., Yang, M.-C.: Is a diabetes pay-for-performance program cost-effective under the National Health Insurance in Taiwan? Qual. Life Res. Int. J. Qual. Life Asp. Treat. Care Rehabil. 23, 687–696 (2014)CrossRefGoogle Scholar
  24. 24.
    World Health Organization: Impact of a pay-for-performance programme on French GPs’ consultation length. World Health Organization, Geneva (2014)Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2015

Authors and Affiliations

  1. 1.Aix Marseille Université (Aix Marseille School of Economics, SESSTIM UMR912)MarseilleFrance
  2. 2.Aix Marseille Université (Aix Marseille School of Economics, GREQAM UMR7316)MarseilleFrance
  3. 3.ORS PACA, Observatoire Régional de la Santé Provence-Alpes-Côte d’AzurMarseilleFrance
  4. 4.IHU, Fondation Méditerranée InfectionMarseilleFrance

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