Paying or Charging Patients?

Paying or Charging Patients?

The NHS is constituted to provide care that is free at the point of use. However, even in the NHS, patients sometimes have to contribute (make co-payments) – for example, a prescription charge is levied on patients who do not qualify for exemption. What about the reverse – paying patients to adopt healthy behaviours, such as adhering to recommended treatment? Pregnant women in some parts of France have been incentivised to attend antenatal clinics, for example,[1] while Theresa Marteau’s team has found that financial incentives were superior to other methods in increasing cigarette quit rates.[2] There are many examples of incentive payments in terms of cash or an opportunity to participate in a lottery in low-income countries.[3]

CLAHRC WM is very interested in the effect of individual incentives and co-payments on uptake of services. CLAHRC WM collaborator Ivo Vlaev is co-investigator for a trial on financial incentives for diabetic retinal screening with three arms – control; money payment; and participation in a lottery. We have identified two recent systematic reviews dealing with this topic – one on the effect of co-payments on utilisation of services in high-income countries; and the other on incentive payments in low-income countries. The former study finds that even small co-payments suppress demand. The latter study appears to be a mirror image with the reciprocal finding that small incentive payments stimulate uptake. More data are needed; so far our evidence base is financial flows from patients in high-income settings, and financial flows to patients in low-income countries. However, the evidence suggests that money flow in either direction is associated with high elasticity of demand. This concept of reciprocal responses as money is made available or withdrawn is represented in the figure. The origin is the point where the service is free at the point of use and there is no incentive payment. This origin is represented at around 50% uptake of service, but could lie anywhere between 0% and 100%, depending on the service concerned.

Graph showing Update against Incentive payment / Co-payment, with a  negative Sigmoidal curve passing through the origin at (0,0)
Figure: Representation of change in service utilisation by cost transfers

We would be pleased to hear from other scholars who wish to collaborate with us on populating the above graph. This would answer many questions, for example, is the graph symmetric, or is the graph steeper for incentive payments than for co-payments?

— Richard Lilford, CLAHRC WM Director


  1. McQuide PA, Delvaux T, Buekens P. Prenatal Care Incentives in Europe. J Public Health Policy. 1998; 19: 331-49.
  2. Ierfino D, Mantzari E, Hirst J, Jones T, Aveyard P, Marteau TM. Financial incentives for smoking cessation in pregnancy: a single-arm intervention study assessing cessation and gaming. Addiction. 2015; 110(4): 680-8.
  3. Lagarde M, Haines A, Palmer N. Conditional cash transfers for improving uptake of health interventions in low- and middle-income countries: a systematic review. JAMA. 2007; 298(16): 1900-10.

One thought on “Paying or Charging Patients?”

  1. Thank you Richard for a though provoking piece, which was amplified by an excellent visual presentation. I had not considered a lottery as an incentive for patients. In high income countries millions play the lotto every week and TV shows like ‘BGT’ and ‘I Am Celebrity…’ survive (even flourish) on our hopes of winning a luxury car by entering a virtual lottery. Is a lottery to incentives health care any different to change the behaviour of patients? It might sit uncomfortably with many people, but the data would suggest otherwise.

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