Cash incentives to low-income people with new health coverage can encourage primary care visits

An economic experiment to inform policymakers considering Medicaid expansion shows small cash incentives to low-income people with new health care coverage can promote primary care visits that may significantly reduce costs overall. The study, by Cathy Bradley, professor of health systems management and policy at the Colorado School of Public Health at CU Anschutz, published today in the August issue of Health Affairs.

"This shows a potential for cost savings for a very small amount of money," Bradley said. "Access to primary care does not necessarily mean a visit will occur. Establishing a primary care relationship with an initial visit helps prevent chronic conditions, avoids hospitalizations and use of emergency departments and provides better care to the patient."

Some employers use cash incentives to encourage healthy behaviors among workers and the Affordable Care Act expanded the use of such incentives to public insurance programs.

"At the time this experiment began, Medicaid expansions were happening across the US," Bradley said.

Previous studies reported that low-income patients could be especially responsive to financial incentives like cost-sharing responsibility for emergency department use.

"An emergency room visit would treat the patient's immediate acute need and discharge them," Bradley said. "A primary care doctor will do all the things that improve their well-being and prevent a medical crisis."

In a randomized controlled trial with subjects in Virginia living 100 percent below the federal poverty level, researchers studied low-income adults newly covered by a primary care program to determine if a cash incentive could encourage them to make an initial visit to a primary care provider. Among four total participant groups, three were given a baseline survey by telephone and then either $50, $25 or $0 to visit their provider within six months. A control group received no incentive or contact from the researchers.

The findings also suggest that interaction with a health care program coordinator who shows low-income enrollees through the system may also encourage primary care visits without further cash incentives. In the $0 incentive group, more people sought and received care than the unpaid control group.

"It shows that for a small amount of money and a conversation you can get a person to obtain primary care," Bradley said.

Subjects in the $50 and $25 incentive groups were more likely to see a primary care provider (77 percent and 74 percent, respectively) compared to the $0 group (68 percent). In the control group, 61 percent received care.

Study subjects were identified and enrolled through a community-based primary care program from a safety-net health care provider in Virginia serving low-income patients. All were newly enrolled in a health care program and had not seen a primary care provider or specialist in the previous nine months.

Overall, 1,228 participants were included in the three incentive groups and completed the baseline interview. There were 414 in the control group.

Bradley said the biggest limitation to the study was recruitment. A significant amount of potential subjects did not have stable phone connectivity, were homeless or incarcerated, making study enrollment a challenge.