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The impact of removing financial incentives from clinical quality indicators: longitudinal analysis of four Kaiser Permanente indicators

BMJ 2010; 340 doi: (Published 11 May 2010) Cite this as: BMJ 2010;340:c1898
  1. Helen Lester, professor of primary care1,
  2. Julie Schmittdiel, research scientist2,
  3. Joe Selby, director2,
  4. Bruce Fireman, biostatistician2,
  5. Stephen Campbell, senior research fellow3,
  6. Janelle Lee, senior data analyst2,
  7. Alan Whippy, director of quality and safety4,
  8. Philip Madvig, associate executive director5
  1. 1NIHR School for Primary Care Research, Manchester M13 9PL
  2. 2Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
  3. 3National Primary Care Research and Development Centre, University of Manchester, Williamson Building, Oxford Road, Manchester M13 9PL
  4. 4Quality and Operations Support, Permanente Medical Group, Oakland, CA
  5. 5Permanente Medical Group, Oakland, CA
  1. Correspondence to: H Lester Helen.lester{at}
  • Accepted 16 January 2010


Objective To evaluate the effect of financial incentives on four clinical quality indicators common to pay for performance plans in the United Kingdom and at Kaiser Permanente in California.

Design Longitudinal analysis.

Setting 35 medical facilities of Kaiser Permanente Northern California, 1997-2007.

Participants 2 523 659 adult members of Kaiser Permanente Northern California.

Main outcomes measures Yearly assessment of patient level glycaemic control (HbA1c <8%), screening for diabetic retinopathy, control of hypertension (systolic blood pressure <140 mm Hg), and screening for cervical cancer.

Results Incentives for two indicators—screening for diabetic retinopathy and for cervical cancer—were removed during the study period. During the five consecutive years when financial incentives were attached to screening for diabetic retinopathy (1999-2003), the rate rose from 84.9% to 88.1%. This was followed by four years without incentives when the rate fell year on year to 80.5%. During the two initial years when financial incentives were attached to cervical cancer screening (1999-2000), the screening rate rose slightly, from 77.4% to 78.0%. During the next five years when financial incentives were removed, screening rates fell year on year to 74.3%. Incentives were then reattached for two years (2006-7) and screening rates began to increase. Across the 35 facilities, the removal of incentives was associated with a decrease in performance of about 3% per year on average for screening for diabetic retinopathy and about 1.6% per year for cervical cancer screening.

Conclusion Policy makers and clinicians should be aware that removing facility directed financial incentives from clinical indicators may mean that performance levels decline.


  • Contributors: HL had the original idea for the study and is guarantor. HL, JSch, and JS planned the study. BF and JL did the statistical analysis. All authors were involved in discussing the emerging data and in writing and revising the paper, had full access to all of the data (including statistical reports and tables) in the study, and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding: None.

  • Competing interests: All authors have completed the Unified Competing Interest form at (available on request from the corresponding author) and declare that all authors had: (1) No financial support for the submitted work from anyone other than their employer; (2) No financial relationships with commercial entities that might have an interest in the submitted work; (3) No spouses, partners, or children with relationships with commercial entities that might have an interest in the submitted work; (4) HL and SC are contracted to the National Institute for Health and Clinical Excellence to provide advice on removal of indicators and pilot new indicators for the Quality and Outcomes Framework. The views expressed are those of the authors and do not necessarily represent the views of NICE or its independent Quality and Outcomes Framework advisory committee.

  • Ethical approval: Not required.

  • Data sharing: The technical appendix, statistical code, and dataset are available from the corresponding author at Helen.lester{at}

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