This proposal describes the rationale for, and the design of, a study to compare and evaluate alternative approaches to primary prevention in a prepaid individual practice association (IPA) setting. Physicians will be allocated at random to three separate intervention groups: first, a group which will be eligible for reimbursement for risk factor patient counseling; second, a group in which patients will be eligible for a cash reward for successfully modifying high risk behavior; and finally, a group which combines both intervention strategies. Comparisons with respect to a customary practice group will be made. The risk factor status of patients, patient and physician satisfaction, acceptability of the intervention strategies themselves, and costs relative to the present value of future benefits will be measured. Smoking status will serve as a tracer risk factor for evaluating the relative effectiveness of the multiple intervention strategies. Because the IPA combines various aspects of the fee for service environment together with the prepaid environment, the results of the proposed study have potential implications which go far beyond the IPA. The results of this study may provide insight into ways in which similar outcomes can be achieved in fee for service practice settings as well.
