The merits of using financial incentives to improve clinical quality have much appeal, yet few studies have rigorously assessed the potential benefits. The uncertainty surrounding assessments of quality can lead to poor policy decisions, possibly resulting in increased cost with little or no quality improvement, or missed opportunities to improve care. We conducted an experiment involving physicians in thirty Philippine hospitals that overcomes many of the limitations of previous studies. We measured clinical performance and then examined whether modest bonuses equal to about 5 percent of a physician's salary, as well as system-level incentives that increased compensation to hospitals and across groups of physicians, led to improvements in the quality of care. We found that both the bonus and system-level incentives improved scores in a quality measurement system used in our study by ten percentage points. Our findings suggest that when careful measurement is combined with the types of incentives we studied, there may be a larger impact on quality than previously recognized.

Improving clinical performance using measurement and payment incentives, including pay for performance (or P4P), has, so far, shown modest to no benefit on patient outcomes. Our objective was to assess the impact of a P4P programme on paediatric health outcomes in the Philippines. We used data from the Quality Improvement Demonstration Study. In this study, the P4P intervention, introduced in 2004, was randomly assigned to 10 community district hospitals, which were matched to 10 control sites. At all sites, physician quality was measured using Clinical Performance Vignettes (CPVs) among randomly selected physicians every 6 months over a 36-month period. In the hospitals randomized to the P4P intervention, physicians received bonus payments if they met qualifying scores on the CPV. We measured health outcomes 4-10 weeks after hospital discharge among children 5 years of age and under who had been hospitalized for diarrhoea and pneumonia (the two most common illnesses affecting this age cohort) and had been under the care of physicians participating in the study. Health outcomes data collection was done at baseline/pre-intervention and 2 years post-intervention on the following post-discharge outcomes: (1) age-adjusted wasting, (2) C-reactive protein in blood, (3) haemoglobin level and (4) parental assessment of child's health using general self-reported health (GSRH) measure. To evaluate changes in health outcomes in the control vs intervention sites over time (baseline vs post-intervention), we used a difference-in-difference logistic regression analysis, controlling for potential confounders. We found an improvement of 7 and 9 percentage points in GSRH and wasting over time (post-intervention vs baseline) in the intervention sites relative to the control sites (P ≤ 0.001). The results from this randomized social experiment indicate that the introduction of a performance-based incentive programme, which included measurement and feedback, led to improvements in two important child health outcomes.

Objective-To examine whether delays in seeking care are associated with worse health outcomes or increased treatment costs in children, and then assess if insurance coverage reduces these delays.Study design-We use data on 4070 children under 5 years from the Quality Improvement Demonstration Study (QIDS), a randomized controlled experiment assessing the effects of increasing insurance coverage. We examined if delay in care, defined as greater than two days between the onset of symptoms and admission to the study district hospitals, is associated with wasting or having positive C-Reactive Protein (CRP) levels upon discharge, and with total charge for hospital admission, and, evaluated whether increased benefit coverage and enrollment, reduced the likelihood of delay.Results-Delay is associated with 4.2 and 11.2 percentage point increase in the likelihood of wasting (p=0.08) and having positive CRP levels (p=0.03), respectively, at discharge. On average hospitalization costs were 1.9% higher with delay (p=0.04). Insurance intervention results in 5 additional children in 100 to not delay going to the hospital (p =0.02).Conclusions-In this population, delayed care is associated with worse health outcomes and higher costs. Access to insurance reduced delays, thus, insurance interventions may have positive effects on health outcomes. Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. The finding that insurance reduces delays and improves health outcomes is especially important for low income countries where child health status is worse and relative out-of-pocket payments for care are high. 15 The supposition is that delays in care contribute to worse health outcomes and higher costs. A related question is whether insurance coverage mitigates against these delays, and if children seek care earlier when out-of-pocket payments are reduced through insurance. If we can show the same results in a middle income country setting, then this suggests insurance can be a potent instrument with which to improve access and improve health outcomes. NIH Public AccessThe presence of a unique randomized experiment in the Philippines provided us with an opportunity to replicate these results in a developing country setting where the financial burden of care is high. Using the child patient exit data from the Quality Improvement Demonstration Study (QIDS), a large randomized controlled experiment assessing the effects of increasing insurance coverage, we perform three analyses in this paper: (1) examine whether children who delay have a worsening of their health status, (2) estimate the impac...

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