Financial Incentive Programs Research Articles

Adolescent and parent perspectives on the acceptability of financial incentives to promote self-care in adolescents with type 1 diabetes.

An understanding of acceptability among potential intervention participants is critical to the design of successful real-world financial incentive (FI) programs. The purpose of this qualitative study was to explore adolescent and parent perspectives on the acceptability of using FI to promote engagement in diabetes self-care in adolescents with type 1 diabetes (T1D). Focus groups with 46 adolescents with T1D (12-17 years old) and 39 parents of adolescents with T1D were conducted in the Seattle metropolitan area. Semistructured questions addressed participants' current use of incentives to promote change in diabetes self-care and receptivity to a theoretical incentive program administered by a third-party. Qualitative data were analyzed and emergent themes identified. Three thematic categories informed participant views about the acceptability of FI programs: (a) the extent to which using FIs in the context of diabetes management fit comfortably into a family's value system, (b) the perceived effectiveness for FIs to promote improved diabetes self-care, and (c) the urgent need for improved self-care due to the threat of diabetes-related health complications. These factors together led most parents and adolescents to be open to FI program participation. The results from this qualitative study suggest that well-designed FI programs to support diabetes management are acceptable to families with adolescents with T1D. Additionally, the use of FIs may have the potential to support adolescents with T1D in developing strong self-care habits and ease the often-turbulent transition to independent self-care.

Evaluating the Feasibility, Acceptability, and Effects of Deposit Contracts With and Without Daily Feedback to Promote Physical Activity.

Despite interest in financial incentive programs, evidence regarding the feasibility, acceptability, and effectiveness of deposit contracts (ie,use of participants' own money as a financial reward) for increasing physical activity (PA) is limited. Furthermore, evidence regarding the use of feedback within incentive programs is limited. To evaluate: (1)the feasibility and acceptability of deposit contracts for increasing objectively measured PA and (2)the effects of deposit contracts with or without ongoing feedback on PA. Participants (n = 24) were exposed to 3 conditions (1)self-monitoring, (2)incentive, and (3)incentive with feedback in an ABACABAC design, with the order of incentive conditions counterbalanced across participants. Effect sizes suggest that individuals had a modest increase in PA during the incentive conditions compared with self-monitoring. Presentation order moderated results, such that individuals exposed to incentives with feedback first performed more poorly across both incentive conditions. In addition, individuals often cited the deposit contract as a reason for not enrolling, and those who did participate reported inadequate acceptability of the incentives and feedback. Results suggest that while deposit contracts may engender modest increases in PA, this type of incentive may not be feasible or acceptable for promoting PA.

TRIal to slow the Progression Of Diabetes (TRIPOD): study protocol for a randomized controlled trial using wireless technology and incentives

BackgroundThe outcomes for those with type 2 diabetes mellitus (T2DM) in Singapore are poor. In this TRIal to slow the Progression Of Diabetes (TRIPOD), we will evaluate the effectiveness and cost-effectiveness of a comprehensive diabetes management package (DMP), with or without a financial incentives program, M-POWER Rewards, in efforts to improve HbA1c levels for individuals with T2DM.Methods/designTRIPOD is a randomized, open-label, controlled, multi-center, superiority trial with three parallel arms: (1) usual care only, (2) usual care with DMP, and (3) usual care with DMP plus M-POWER Rewards. A total of 339 adults with sub-optimally controlled T2DM (self-reported HbA1c 7.5–11.0%) will be block randomized according to a 1:1:1 allocation ratio to the three arms. The primary outcome is mean change in HbA1c level at Month 12 from baseline. Secondary outcomes include mean change in HbA1c level at Months 6, 18, and 24; mean changes at Months 6, 12, 18, and 24 in weight, blood pressure, and self-reported physical activity, weight monitoring, blood glucose monitoring, medication adherence, diabetes self-management, sleep quality, work productivity and daily activity impairment, and health utility index; and proportion of participants initiating insulin treatment by Months 6, 12, 18, and 24. Incremental cost-effectiveness ratios will be computed based on costs per improvement in HbA1c at Month 12 and converted to cost per quality-adjusted life year gained.DiscussionThe TRIPOD study will present insights about the long-term cost-effectiveness and financial viability of the interventions and the potential for integrating within usual care.Trial registrationClinicalTrials.gov, NCT03800680. Registered on 11 January 2019.

Optimal Design of Population-Level Financial Incentives of Influenza Vaccination for the Elderly

ObjectivesTo identify how monetary incentives affect influenza vaccination uptake rate using a randomized control experiment and to subsequently design an optimal incentive program in Singapore, a high-income country with a market-based healthcare system. Methods4000 people aged ≥65 were randomly assigned to 4 treatment groups (1000 each) and were offered a monetary incentive (in shopping vouchers) if they chose to participate. The baseline group was invited to complete a questionnaire with incentives of 10 Singapore dollars (SGD; where 1 SGD ≈ 0.73 USD), whereas the other three groups were invited to complete the questionnaire and be vaccinated against influenza at their own cost of around 32 SGD, in return for incentives of 10, 20, or 30 SGD. ResultsIncreasing the total incentive for vaccination and reporting from 10 to 20 SGD increased participation in vaccination from 4.5% to 7.5% (P < .001). Increasing the total incentive from 20 to 30 SGD increased the participation rate to 9.2%, but this was not statistically significantly different from a 20-SGD incentive. The group of nonworking elderly were more sensitive to changes in incentives than those who worked. In addition to working status, the effects of increasing incentives on influenza vaccination rates differed by ethnicity, socio-economic status, household size, and a measure of social resilience. There were no significant differential effects by age group, gender, or education, however. The cost of the program per completed vaccination under a 20-SGD incentive is 36.80 SGD, which was the lowest among the three intervention arms. For a hypothetical population-level financial incentive program to promote influenza vaccination among the elderly, accounting for transmission dynamics, an incentive between 10 and 20 SGD minimizes the cost per completed vaccination from both governmental and health system perspectives. ConclusionsAppropriate monetary incentives can boost influenza vaccination rates. Increasing monetary incentives for vaccination from 10 to 20 SGD can improve the influenza vaccination uptake rate, but further increasing the monetary incentive to 30 SGD results in no additional gains. A partial incentive may therefore be considered to improve vaccination coverage in this high-risk group.

Importance of the Supplemental Nutrition Assistance Program in Rural America.

There is great interest in reshaping the Supplemental Nutrition Assistance Program (SNAP) so that it better supports family nutrition, and an array of program changes have been proposed.We note the importance of considering the unique needs of rural SNAP participants when considering and implementing these changes. We also describe the SNAP-related needs and challenges unique to rural SNAP participants, and through this lens we discuss changes to SNAP that have been proposed and special considerations related to each. The special considerations we identified include allowing canned, frozen, and dried fruits and vegetables as eligible items in financial incentive programs in rural areas; changing direct education programming to address transportation-related barriers many rural families face in attending in-person classes; and supporting rigorous research to evaluate the potential benefits and unintended consequences of proposed program changes for which scant high-quality evaluation data exist.Evaluation studies should include rural SNAP participants so that effects in this important population group are known.

Effectiveness of a low-value financial-incentive program for increasing vegetable-rich restaurant meal selection and reducing socioeconomic inequality: a cluster crossover trial

BackgroundIn light of recent theories in behavioural economics, an intervention program with monetary incentives could be effective for helping patrons order healthy food, even if the incentive is small and less than one’s perceived marginal value.MethodsIn this single-arm cluster crossover trial at 26 local restaurants, a 1-week campaign offered a 50-yen (approximately 0.5 US dollars) cash-back payment to customers ordering vegetable-rich meals, while no pre-order incentives were offered during the control period.ResultsIn total, 511 respondents out of 7537 customers (6.8%), and 704 respondents out of 7826 customers (9.0%), ordered vegetable-rich meals during the control and intervention periods, respectively. During the intervention period, the covariate-adjusted proportion of vegetable-rich meal orders was 1.50 times higher (95% confidence interval [CI]: 1.29 to 1.75), which increased daily sales by 1.77 times (95% CI: 1.11 to 2.83), even when subtracting the cost of cash-back payments. Respondents who reported spending the least amount of money on eating out (used as a proxy measure for income) were the least likely to order vegetable-rich meals during the control period. However, these individuals increased their proportion of purchasing such meals during the intervention period (a 3.8 percentage point increase (95% CI: 2.82 to 4.76) among those spending the least vs a 2.1 percentage point increase (95% CI: 1.66 to 2.62) among those spending the most; P for interaction = 0.001). Similarly, irregular employees exhibited a larger increase (+ 5.2 percentage points, 95% CI: 4.54 to 5.76) than did regular workers (− 1.4, 95% CI: − 1.66 to − 1.05, P for interaction = 0.001).ConclusionsA program with an immediate low-value monetary incentive could be a public health measure for reducing inequalities in making healthy food choices.Trial registrationUMIN Clinical Trials Registry, UMIN000022396. Registered 21 May 2016.

The reality of the job leakage in the General Corporation for Desalination of Saline Water in Jubail Station: واقع التسرب الوظيفي في المؤسسة العامة لتحلية المياه المالحة بمحطة الجبيل

The study aimed to find out the causes of Job Dropout in the General Corporation for Saline Water Conversion in Jubail. The study used the survey method. The population of the study were (1900)، and the results reached the most important results: The sample highly approved by (74. 6%) and a mean of (3. 73). And that the stability of salary without bonuses is the most important of these reasons and may be attributed to the weakness of the organizational structure in the institution and not to update. The study also revealed that the physical and organizational dimension is considered to be the most important cause of the Job Dropout in the firm، with an average of (4. 73) percentage، 87. 4%. And that the provision of medical insurance was arithmetic repetition of (123) percent by 95. 4 percent، as well as the non-provision of housing allowance was of arithmetic repetition of (114) and 88. 4 percent. The study also showed that after social and personal factors came to a medium degree. The responses to this dimension were averaged (33. 3) and 66. 6%. The responses of (119) individuals، 92. 3%، indicated that they prefer to drop out of the institution when there are offers at another establishment. The study concluded the following recommendations: The need for the organization to know the reasons for the leakage of its employees by making sure to interview with the actual dropouts and to benefit from this information in the reformulation of future policies for human resources. Approval of medical insurance programs for employees of the General Corporation for Desalination of Salt Water in Jubail. Review the organizational and administrative structure. Review and amend the upgrade regulations in force in the institution in proportion to similar establishments. Provision of housing allowance for the employees of the institution for those who do not have housing. Revising and working on the financial incentive program to distribute it fairly.

Challenges of Energy Efficiency Promoting Policy in Thailand

Energy efficiency enhancement is well recognized worldwide as the efficient measures to deal with energy-related challenges, which are economic growth and development, energy security, and climate change. For Thailand to accelerate energy efficiency implementation, the energy development plan is set to meet the national targets including the Energy Efficiency Plan target and to achieve the Greenhouse Gas emission reduction target. In many countries, financing energy efficiency promoting policy is critically important strategy to provide financial incentive for mitigating clean energy investment barrier. For long-term public support, there is an emerging body of evidence on the on-going practice and performance of the financial incentive programs, which offers an opportunity to improve our understanding of the energy efficiency promoting policy. This study reviewed the latest situation of three energy efficiency financial incentive programs that governed by Department of Alternative Energy Development and Energy Efficiency (DEDE), which are (1) Energy Efficiency Revolving Fund (EERF), (2) Energy Service Company Revolving Fund (ESCO Fund), (3) DEDE Demand Side Management Bidding (DSM Bidding). The study aims to examine the positive and negative challenges posed by existing policies that need to be overcome and to identify the opportunities for policy improvement to more effectively promote energy efficiency implementation. EERF and DSM Bidding are suitably designed for large company who has strong financial capacity. ESCO Fund is well-designed for low collateral capacity company. EE measures under EERF are mostly well-known technologies that are proven generating energy savings. ESCO Fund is suitable for promoting new technologies according to project-based analysing basis. DSM Bidding can be designed for wide-range EE measures from simple to complex measures. However, there are some main challenges that can be improved, i.e., technical and financial risks bearing by customers from EERF, default projects risk taken by government and insufficient to encourage EE investment of low interest rate from ESCO Fund, and expanding to support more for complex technology instead of only well-known technology for DSM Bidding.

The Effect of a Primary Care Provider Incentive Program on Pediatric Emergency Medicine Visits.

The aim of the study was to analyze the effect of a financial incentive program targeting primary care providers (PCPs) with the goal of decreasing emergency department (ED) utilization. We performed a retrospective cohort analysis in a single health maintenance organization comparing ED visit/1000 member-months before and after the physician incentive program in 2009. We compared the median ED visit rate between physicians who did (PIP) and did not participate (non-PIP) from 2009 to 2012. We used 2008 data as a baseline study period to compare the ED visit rate between PIP and non-PIP providers to detect any inherent difference between the 2 groups. A total of 1376 PCPs were enrolled. A total of US $18,290,817 was spent in total on incentives. Overall, the median ED visit rate for all providers was statistically significantly lower during the study period (baseline period, study period: 56.36 ED visits/1000 member-months vs 45.82, respectively, P < 0.001). During the baseline period in our fully adjusted linear regression for degree, specialty, education, and board status, PIP versus non-PIP visits were not statistically significantly different (P = 0.17). During the study period in our fully adjusted model, we found that PIP had statistically significant fewer ED visits compared with non-PIP (P = 0.02). In a subgroup analysis of providers who did and did not receive an incentive payment, in the fully adjusted linear regression, providers who received any payment had statistically significant fewer ED visits/1000 member-months (P < 0.001). In addition, we found in the fully adjusted analysis that those providers who received at least 1 incentive payment for meeting after-hours criteria had statistically significantly fewer ED visits/1000 member-months (P < 0.001). A financial incentive program to provide PCPs with specific targets and goals to decrease pediatric ED utilization can decrease ED visits.

Financial incentives and maternal health: where do we go from here?

Health financing strategies that incorporate financial incentives are being applied in many low- and middle-income countries, and improving maternal and neonatal health is often a central goal. As yet, there have been few reviews of such programmes and their impact on maternal health. The US Government Evidence Summit on Enhancing Provision and use of Maternal Health Services through Financial Incentives was convened on 24-25 April 2012 to address this gap. This article, the final in a series assessing the effects of financial incentives--performance-based incentives (PBIs), insurance, user fee exemption programmes, conditional cash transfers, and vouchers--summarizes the evidence and discusses issues of context, programme design and implementation, cost-effectiveness, and sustainability. We suggest key areas to consider when designing and implementing financial incentive programmes for enhancing maternal health and highlight gaps in evidence that could benefit from additional research. Although the methodological rigor of studies varies, the evidence, overall, suggests that financial incentives can enhance demand for and improve the supply of maternal health services. Definitive evidence demonstrating a link between incentives and improved health outcomes is lacking; however, the evidence suggests that financial incentives can increase the quantity and quality of maternal health services and address health systems and financial barriers that prevent women from accessing and providers from delivering quality, lifesaving maternal healthcare.

Social marketing including financial incentive programs at worksite cafeterias for preventing obesity: a systematic review

BackgroundAs with food-taxation strategies, such interventions as discounted healthy menus, point-of-purchase advertisements, and sugar-free beverages for employees at worksites could help prevent obesity. This study assessed the effectiveness of food environment interventions incorporating financial incentive or social marketing strategies at workplace cafeterias, vending machines, and kiosks toward preventing obesity and improving dietary habits.MethodsWe conducted searches on CENTRAL, MEDLINE, EMBASE, CINAHL, and PsycINFO databases. The study designs included were randomized control trials (RCTs) and cluster RCTs. We evaluated the effectiveness of financial incentive or social marketing strategies interventions (such as discounts) on health outcomes or food intake behavior. Two reviewers independently screened the studies for inclusion. We assessed the risk of bias using the Cochrane Collaboration’s tool. This protocol was published in 2014.ResultsWe included three trials, with a combined total of 3013 participants. There were limited available data from RCTs on changes in body weight. No eligible social marketing studies were retrieved. In some cases, a meta-analysis could not be conducted owing to differences in the analytic methods for the outcomes.ConclusionsLack of evidence made it difficult to draw any conclusions. In future surveys, it will be necessary to conduct interventions focusing only on financial incentive intervention versus no intervention in order to determine whether the incentive strategy has a clear impact.Systematic review registrationPROSPERO CRD4201401056

The Influence of Loan Repayment and Scholarship Programs on Healthcare Provider Retention in Underserved Kansas

Background. In an effort to redistribute healthcare providersto underserved areas, many states have turned to financialincentive programs. Despite substantial research on theseprograms on a national scale, little is known about the successof such programs in Kansas. The purpose of this studywas to provide insight into the relationship between financial incentive programs and provider retention in Kansas.&#x0D; Methods. A cross-sectional telephone survey was conducted inApril and May of 2011 with participants who had completedtheir obligations to the Kansas State Loan Repayment Program(SLRP), the National Health Service Corps (NHSC) Loan Repaymentprogram, or the National Health Service Corps Scholar shipprogram in Kansas between January 2006 and January 2011.&#x0D; Results. Of the 112 providers included in the study, 54.4% (n = 61)had left their program sites sometime after finishing their commitment,with the mean length of stay after the obligation periodended being 7.3 (median = 3) months. Of the 54 participants whohad left their program sites and whose current locations wereknown, 33.3% (n = 18) were located in new Health ProfessionalShortage Areas (HPSA), 25.9% (n = 14) were in a new non-HPSA,and 40.7% (n = 22) had left the state. Family satisfaction with thecommunity and attending a professional school in Kansas wereassociated statistically with retention of physicians in Kansas.&#x0D; Conclusions. Nearly half of all participants had remained attheir sites even after their obligation period ended, with familysatisfaction with the community appearing to be the strongestpredictor for retention among those who had stayed.Efforts to match a provider’s family with the community successfullyand to support the family through networking mayimprove future provider retention. KS J Med 2016;9(1):6-11.

Why Money Alone Can't (Always) "Nudge" Physicians: The Role of Behavioral Economics in the Design of Physician Incentives.

Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.

Should Trainees Get Paid to Submit Patient Safety Reports?

In the December 2018 issue of the Journal of Graduate Medical Education, Turner and colleagues1 describe a financial incentive program aimed at increasing the number of patient safety reports submitted by residents and fellows. The researchers found that implementing this program, which included a new online reporting system, an educational initiative, and financial incentives, resulted in an increase in trainee reports of safety events. Preincentive, less than 0.5% of submitted safety reports came from trainees, but after the new program was implemented, 7% originated from this group. At first look, these outcomes are tantalizing, yet they raise questions that should be further pursued.First, it may be necessary to question the underlying premise of the study—that more reporting by residents and fellows improves the quality of patient care. Turner and colleagues1 acknowledge that this might not be the case, noting that “an increase in safety event reporting by itself will not achieve the desired impact on patient safety unless reporting is paired with robust feedback and demonstrable changes in practice.” We believe this is a critical issue, but the authors do not include data that show a link between reporting and quality. There is evidence that in US states where reporting of adverse events is mandatory, reports submitted by individuals (contrasted with automated reporting) have improved safety and reduced harm at the institutional level after root cause analysis.2 However, this positive outcome was found in the context of (1) voluntary reporting and (2) conducting a root cause analysis. We wonder whether voluntary reporting is comparable to incentivized reporting and whether root cause analyses were conducted following the receipt of the incentivized safety reports.It is also conceivable that increasing the number of reports by trainees may not result in patient safety improvements because the event the trainee is reporting has already been reported by someone else. Turner and colleagues1 indicate that in 2014–2015, trainees submitted 1288 reports. It would be interesting to know what percentage of these reports were for events not previously submitted by another health professional. If the bulk of the trainee reports are related to events already reported by others, it is unclear what value the duplicate report holds.We also wonder whether the $200 per year an individual trainee can receive for meeting the patient safety report metric may create an incentive to overreport or to create trivial reports. Is it known whether all trainee-reported events warranted reporting or whether duplicate reports were entered to increase the numbers? More details in this area would help assuage concerns that trainee reports could be motivated by factors other than the goal of improving patient care. A follow-up study might assess a trainee's ability to define and describe what event types and scenarios are reportable based on the institution's standards.Finally, we want to note a study interpretation issue: correlation is not causation. The authors do acknowledge this in their limitations section, but it does not stop them from drawing causal conclusions such as “an incentive program . . . can substantially increase GME reporting of patient safety events.” We do not believe the methodology supports such a conclusion. Most critical is that the study has several interventions. Rates of safety event reporting increased after residents and fellows completed a required educational training, after a link for the reporting site was added to a resident web page, and after trainees were told about the incentive program. Any of these factors could have contributed to increasing reporting rates. It is also possible that the institutional culture shifted during the study period to become more accepting of open discussions of safety events and reporting—which also could have affected the number of reports. Though it is plausible that the incentive program played an important role in increasing reporting rates, with other variables at play, we do not know whether, or to what extent, this was the case.The reported cost for the intervention was $197,000 for a single year, which is substantial. Providing this level of financial support in the form of incentives to residents and fellows makes sense only if there is evidence that when trainees report patient safety events, patient care improves. Since a significant barrier in voluntary reporting is an absence of feedback to the reporter, organizations should consider whether they would be better served by investing in broad feedback mechanisms to relay the outcome of safety event reports rather than investing in incentivizing event reporting.

Do rural incentives payments affect entries and exits of general practitioners?

Many countries use financial incentive programs to attract physicians to work in rural areas. This paper examines the effectiveness of a policy reform in Australia that made some locations newly eligible for financial incentives and increased incentives for locations already eligible. The analysis uses panel data (2008–2014) on all Australian general practitioners (GPs) aggregated to small areas. We use a difference-in-differences approach to examine if the policy change affected GP entry or exit to the 755 newly eligible locations and the 787 always eligible locations relative to 2249 locations which were never eligible. The policy change increased the entry of newly-qualified GPs to newly eligible locations but had no effect on the entry and exit of other GPs. Our results suggest that location incentives should be targeted at newly qualified GPs.

Socioecological system and potential deforestation in Western Amazon forest landscapes

The ecosystem services provided by tropical forests are affected by deforestation. Territorial management strategies aim to prevent and mitigate forest loss. Therefore, modeling potential land use changes is important for forest management, monitoring, and evaluation. This study determined whether there are relationships between forest vulnerability to deforestation (potential deforestation distribution) and the forest management policies applied in the Ecuadorian Amazon.Proxy and underlying variables were used to construct a statistical model, based on the principle of maximum entropy that could predict potential land use changes. Entropy can be seen as a measure of uncertainty for a density function. Receiver operating characteristics (ROC) analysis and the Jackknife Test were used to validate the model. The importance of input variables in the model was determined through: Percent Contribution (PC) and Permutation Importance (PI). The results were compared with prevailing regional forest management strategies.The socioeconomic variables that provided the largest amount of information in the overall model (AUC = 0.81) and that showed most of the information not present in other variables were: “Protected areas-Intangible zone” (PC = 24%, PI = 12.4%), “timber harvesting programs” (PC = 21.7%, PI = 4.7%), “road network” (PC = 18.9%, PI = 7.7%), and “poverty rate” (PC = 3.7%, PI = 6.1%). Also, the biophysical variable “temperature” (PC = 7,9%, PI = 22.3%) provided information in the overall model.The results suggested the need for changes in forest management strategies. Forest policies and management plans should consider integrating and strengthening protected areas and intangible zones, as well as restricting timber harvesting in native forest and establishing forest areas under permanent management. Furthermore, the results also suggested that financial incentive programs to reduce deforestation have to be evaluated because their present distribution is inefficient. In this context, conservation incentive plans need to be revised so that they focus on areas at deforestation risk.

EPOP-149 - Impact of a Nurse Testing Guide on the Accuracy of Clostridium Difficile Location Onset Classification

Background: The use of healthcare facility-onset Clostridium difficile infection (CDI) data in financial incentive and penalty programs has made the timely identification and testing of CDI patients essential for appropriate classification within the National Healthcare Safety Network (NHSN). NHSN classifies location onset based on specimen collection date; community-onset (CO) on admission day one, two, or three, and healthcare facility-onset (HO) on day four or later. Delay in the identification and testing of potential CDI patients can cause CO-CDI to be misclassified as HO-CDI. To improve the screening process and reduce time to testing one four-campus regional health system implemented a Clostridium difficile nurse testing guide. The guide outlined criteria for testing as three or more watery or loose stools not related to laxatives and allowed nurses to collect a specimen and send for testing without a provider order.

Healthy Food Incentive Impacts on Direct-to-Consumer Sales: A Michigan Example

Numerous interventions have been implemented at farmers markets across the United States in recent years in order to increase Supplemental Nutrition Assistance Program (SNAP) redemptions. These initiatives include ensuring that farmers markets have the technological capability of accepting SNAP and implementing financial incentive programs that provide matching benefits for the redemption of SNAP benefits. While a main objec­tive behind these initiatives is to increase revenue to direct marketing farmers, it is challenging to distinguish between the impacts of distinct inter­ventions. This shortcoming is a significant deter­rent in understanding how to effectively implement policies that enhance such objectives. We examine the impact of Double Up Food Bucks (DUFB), a prominent farmers market financial incentive pro­gram, on county-level direct-to-consumer (DTC) agricultural sales in Michigan. In our models, we distinguish between counties with farmers markets that do not accept SNAP, counties with markets that accept SNAP but not DUFB, and counties with markets that accept DUFB. We also estimate separate models that allow us to distinguish between the presence and magnitude of DUFB on county-level sales. We find that offering DUFB and accepting SNAP benefits were each associated with positive and statistically significant increases in direct marketing sales, and the magnitude of the DUFB coefficient was greater than the SNAP coefficient. Our preliminary evidence from coeffi­cient magnitudes also suggests that the county-level increase in direct sales exceeded the benefit levels.

Hospitais filantrópicos beneficiados por programa de incentivo financeiro: uma análise de desempenho

RESUMO O estado de São Paulo adotou um programa de incentivo financeiro para hospitais filantrópicos. O objetivo deste estudo foi analisar o desempenho dos hospitais participantes desse programa em 2012. Foram analisados os indicadores de desempenho segundo o porte hospitalar e o porte municipal, empregando-se o modelo de desempenho do Proadess (Avaliação de Desempenho do Sistema de Saúde). Encontrou-se diferença no desempenho dos hospitais segundo porte: os hospitais de pequeno porte apresentaram resultados desfavoráveis com relação aos indicadores de acesso, eficiência e efetividade. Esse resultado corrobora a necessidade de reavaliar programas de incentivo financeiro para hospitais de pequeno porte configurados como hospitais gerais.

Factors Associated With Medical School Graduates' Intention to Work With Underserved Populations: Policy Implications for Advancing Workforce Diversity.

Given projected U.S. physician shortages across all specialties that will likely impact underserved areas disproportionately, the authors sought to explore factors most correlated with medical school graduates' intention to work with underserved populations (IWUP). Data from the 2010-2012 Association of American Medical Colleges Medical School Graduation Questionnaire (n = 40,846) were analyzed. Variables (demographics, career preference, debt burden, intention to enter loan forgiveness programs) were examined using chi-square tests and logistic regression models. Respondents included 49.5% (20,228/40,846) women, 16.6% (6,771/40,837) underrepresented minorities (URMs), and 32.4% (13,034/37,342) with primary care intent. The median educational debt was $160,000. Respondents who were women (adjusted odds ratio [aOR] 1.59, 95% confidence interval [CI] 1.49, 1.70), URMs (aOR 2.50, 95% CI 2.30, 2.72), intended to enter loan forgiveness programs (aOR 2.44, 95% CI 2.26, 2.63), intended to practice primary care (aOR 1.65, 95% CI 1.54, 1.76), and intended to emphasize nonclinical careers (aOR 1.23, 95% CI 1.11, 1.37) had greater odds of reporting IWUP. Among those who chose specialties and careers with a nonclinical emphasis, and among those with greater burdens of educational and consumer debt, URMs were nearly twice as likely as other minorities and whites to report IWUP. Findings suggest physician characteristics that may be associated with filling workforce gaps in underserved areas. Restructuring financial incentive programs to support physician leaders and specialists with characteristics associated with IWUP may complement similar policies in primary care and could have key impacts on health equity in underserved areas.