IDEAS home Printed from
   My bibliography  Save this article

How Do Doctors Respond to Incentives? Unintended Consequences of Paying Doctors to Reduce Costs


  • Diane Alexander


Billions of dollars have been spent on pilot programs searching for ways to reduce health care costs. I study one such program, in which hospitals pay doctors bonuses for reducing the total hospital costs of admitted Medicare patients. Doctors respond to the bonuses by becoming more likely to admit patients whose treatment can generate high bonuses and sorting healthier patients into participating hospitals. Conditional on patient health, however, doctors do not reduce costs or change procedure use. These results highlight the ability of doctors to game incentive schemes and the risks of basing nationwide health care reforms on pilot programs.

Suggested Citation

  • Diane Alexander, 2020. "How Do Doctors Respond to Incentives? Unintended Consequences of Paying Doctors to Reduce Costs," Journal of Political Economy, University of Chicago Press, vol. 128(11), pages 4046-4096.
  • Handle: RePEc:ucp:jpolec:doi:10.1086/710334
    DOI: 10.1086/710334

    Download full text from publisher

    File URL:
    Download Restriction: Access to the online full text or PDF requires a subscription.

    File URL:
    Download Restriction: Access to the online full text or PDF requires a subscription.

    File URL:
    LibKey link: if access is restricted and if your library uses this service, LibKey will redirect you to where you can use your library subscription to access this item

    As the access to this document is restricted, you may want to search for a different version of it.


    Blog mentions

    As found by, the blog aggregator for Economics research:
    1. Chris Sampson’s journal round-up for 7th December 2020
      by Chris Sampson in The Academic Health Economists' Blog on 2020-12-07 12:00:03


    Citations are extracted by the CitEc Project, subscribe to its RSS feed for this item.

    Cited by:

    1. Malani, Anup & Holtzman, Phoebe & Imai, Kosuke & Kinnan, Cynthia & Miller, Morgen & Swaminathan, Shailender & Voena, Alessandra & Woda, Bartosz & Conti, Gabriella, 2021. "Effect of Health Insurance in India: A Randomized Controlled Trial," IZA Discussion Papers 14913, Institute of Labor Economics (IZA).
    2. Brosig-Koch, Jeannette & Groß, Mona & Hennig-Schmidt, Heike & Kairies-Schwarz, Nadja & Wiesen, Daniel, 2021. "Physicians' incentives, patients' characteristics, and quality of care: A systematic experimental comparison of fee-for-service, capitation, and pay for performance," Ruhr Economic Papers 923, RWI - Leibniz-Institut für Wirtschaftsforschung, Ruhr-University Bochum, TU Dortmund University, University of Duisburg-Essen.
    3. Anup Malani & Cynthia Kinnan & Gabriella Conti & Kosuke Imai & Morgen Miller & Shailender Swaminathan & Alessandra Voena & Bartosz Woda, 2024. "Evaluating and Pricing Health Insurance in Lower-income Countries: A Field Experiment in India," NBER Working Papers 32239, National Bureau of Economic Research, Inc.
    4. Dillender, Marcus & Jinks, Lu & Lo Sasso, Anthony T., 2023. "When (and why) providers do not respond to changes in reimbursement rates," Journal of Public Economics, Elsevier, vol. 217(C).
    5. Cadena, Brian C. & Smith, Austin C., 2022. "Performance pay, productivity, and strategic opt-out: Evidence from a community health center," Journal of Public Economics, Elsevier, vol. 206(C).
    6. Andy Ye Yuan & Bernard Black & Timea Viragh & David J. Magid & Qian Luo & Ali Moghtaderi, 2023. "Effect of financial incentives on hospital‐cardiologist integration and cardiac test location," Journal of Empirical Legal Studies, John Wiley & Sons, vol. 20(3), pages 570-608, September.
    7. Travova, Ekaterina, 2023. "Under pressure? Performance evaluation of police officers as an incentive to cheat," Journal of Economic Behavior & Organization, Elsevier, vol. 212(C), pages 1143-1172.
    8. Nicholas Benson & Jose Joaquin Lopez, 2024. "Surgeons' response to reimbursement changes for alternative procedures: Evidence from spine fusion in the U.S," Contemporary Economic Policy, Western Economic Association International, vol. 42(1), pages 41-55, January.
    9. Erina Ytsma, 2022. "Effort and Selection Effects of Performance Pay in Knowledge Creation," CESifo Working Paper Series 10153, CESifo.
    10. Attema, Arthur E. & Galizzi, Matteo M. & Groß, Mona & Hennig-Schmidt, Heike & Karay, Yassin & L’Haridon, Olivier & Wiesen, Daniel, 2023. "The formation of physician altruism," Journal of Health Economics, Elsevier, vol. 87(C).
    11. Ahorner, Solveig, 2023. "The Influence of Physician Rating Websites on the Quality of Primary Care," VfS Annual Conference 2023 (Regensburg): Growth and the "sociale Frage" 277615, Verein für Socialpolitik / German Economic Association.

    More about this item


    This item is featured on the following reading lists, Wikipedia, or ReplicationWiki pages:
    1. How Do Doctors Respond to Incentives? Unintended Consequences of Paying Doctors to Reduce Costs (JPE 2020) in ReplicationWiki


    Access and download statistics


    All material on this site has been provided by the respective publishers and authors. You can help correct errors and omissions. When requesting a correction, please mention this item's handle: RePEc:ucp:jpolec:doi:10.1086/710334. See general information about how to correct material in RePEc.

    If you have authored this item and are not yet registered with RePEc, we encourage you to do it here. This allows to link your profile to this item. It also allows you to accept potential citations to this item that we are uncertain about.

    We have no bibliographic references for this item. You can help adding them by using this form .

    If you know of missing items citing this one, you can help us creating those links by adding the relevant references in the same way as above, for each refering item. If you are a registered author of this item, you may also want to check the "citations" tab in your RePEc Author Service profile, as there may be some citations waiting for confirmation.

    For technical questions regarding this item, or to correct its authors, title, abstract, bibliographic or download information, contact: Journals Division (email available below). General contact details of provider: .

    Please note that corrections may take a couple of weeks to filter through the various RePEc services.

    IDEAS is a RePEc service. RePEc uses bibliographic data supplied by the respective publishers.