title: Impact assessment of a pay-for-performance program on breast cancer screening in France using micro data.
abstract: BACKGROUND
  A voluntary-based pay-for-performance (P4P) program (the CAPI) aimed at general practitioners (GPs) was implemented in France in 2009. The program targeted prevention practices, including breast cancer screening, by offering a maximal amount of €245 for achieving a target screening rate among eligible women enrolled with the GP.
  
  
  OBJECTIVE
  Our objective was to evaluate the impact of the French P4P program (CAPI) on the early detection of breast cancer among women between 50 and 74 years old.
  
  
  METHODS
  Based on an administrative database of 50,752 women aged 50-74 years followed between 2007 and 2011, we estimated a difference-in-difference model of breast cancer screening uptake as a function of visit to a CAPI signatory referral GP, while controlling for both supply-side and demand-side determinants (e.g., sociodemographics, health and healthcare use).
  
  
  RESULTS
  Breast cancer screening rates have not changed significantly since the P4P program implementation. Overall, visiting a CAPI signatory referral GP at least once in the pre-CAPI period increased the probability of undergoing breast cancer screening by 1.38 % [95 % CI (0.41-2.35 %)], but the effect was not significantly different following the implementation of the contract.
  
  
  CONCLUSIONS
  The French P4P program had a nonsignificant impact on breast cancer screening uptake. This result may reflect the fact that the low-powered incentives implemented in France through the CAPI might not provide sufficient leverage to generate better practices, thus inviting regulators to seek additional tools beyond P4P in the field of prevention and screening.
authors.affiliation: CESP, Univ. Paris-Sud, UVSQ, INSERM, Université Paris-Saclay, Hôpital Paul Brousse, 16 avenue Paul Vaillant-Couturier, 94807, Villejuif Cedex, France. jonathan.sicsic@inserm.fr.
authors.forename: Jonathan
authors.identifier: http://orcid.org/0000-0002-5509-4791
authors.initials: J
authors.lastname: Sicsic
authors.affiliation: CESP, Univ. Paris-Sud, UVSQ, INSERM, Université Paris-Saclay, Hôpital Paul Brousse, 16 avenue Paul Vaillant-Couturier, 94807, Villejuif Cedex, France.
authors.forename: Carine
authors.initials: C
authors.lastname: Franc
mesh_terms: D000367:Age Factors; D000368:Aged; D001943:Breast Neoplasms / Q000175:diagnosis*; D055088:Early Detection of Cancer / Q000379:methods*; D005260:Female; D005602:France; D058005:General Practitioners / Q000191:economics* / Q000706:statistics & numerical data*; D006296:Health Services / Q000706:statistics & numerical data; D006801:Humans; D007348:Insurance, Health / Q000706:statistics & numerical data; D008327:Mammography; D008875:Middle Aged; D017059:Models, Econometric; D012017:Referral and Consultation / Q000706:statistics & numerical data; D012052:Reimbursement, Incentive / Q000706:statistics & numerical data*; D012959:Socioeconomic Factors
keywords: Breast cancer screening; Difference-in-difference; Incentives; Pay for performance; Primary care