How do you motivate busy physicians to give more flu shots?

Figuring out how to get more people to get an annual flu shot is a pernicious problem in the U.S.: Since 2010, the proportion of American adults who get a flu shot has not risen above 46%, and it hit a low for that period of 37% in 2017. The direct medical costs of the flu are in the tens of billions of dollars each year, and the societal cost runs much higher due to millions of hours of missed work and billions of dollars in lost earnings.

Most interventions targeting patients’ thoughts and feelings have met with little success. But patients aren’t the only way to increase vaccination rates; providers wield significant influence over patient behavior: One study showed that 99% of patients accept the flu shot following a provider recommendation.

But how do you motivate busy providers to vaccinate more of their patients? To address that question, we conducted a randomized controlled experiment to explore whether offering financial incentives or creating competition by informing clinics how their performance ranked relative to others had the biggest impact. To our surprise, we found that the latter was more effective.

To carry out the experiment, we partnered with VaxCare, a technology company whose mission is to “transform the vaccination experience” by working with healthcare clinics to coordinate vaccination logistics. We randomly assigned 145 healthcare clinics scattered across nine different U.S. states to one of three groups.

The clinics in the first group received financial bonuses for year-over-year growth in the number of flu shots they administered: They were paid additional money for all the shots they administered if they hit the growth target. Clinics in the second group were assessed on the same basis as the first but were just informed of their own ranking (the identities of others in the ranking were not disclosed). The third group was the control: The clinics in this group were neither offered a financial incentive for increasing the number of vaccinated patients nor ranked relative to other clinics.

We launched the study in August 2018. By December 2018, it became evident our intervention had worked: The total number of flu shots administered by the first two groups increased by about 6% more than, on average, the total number administered by the control group.

The other significant result: The number of shots administered by clinics that received performance rankings grew almost 10%, while the number administered by clinics that received financial incentives increased by less than 1%.

Our work on flu vaccinations provides four broad takeaways for leaders of care-provider organizations for improving health.

1. While there is a time and place for financial incentives, consider or explore whether non-financial incentives might be more effective in a particular operational context in achieving the desired outcome. In today’s busy world, our attention is often our scarcest resource, and money isn’t always the most effective way to focus our attention on achieving particular goals.
2. Treat Peter Drucker’s dictum “what gets measured gets managed” seriously. In the case of flu vaccinations, high-level measurement hasn’t sufficed: The U.S. Centers for Disease Control and Prevention (CDC) has been measuring overall flu vaccine compliance for years with little effect. But as our study shows, measuring individuals’ performance relative to a group of peers and then sharing that information in a way that they can consume and then use for improvement can have a significant impact. In other words, make it personal.
3. Weigh whether sharing feedback privately or publicly is more appropriate. Public feedback can be useful for sharing best practices: It publicly identifies the high performers, allowing others to seek them out for advice. But in situations where publicizing everyone’s results risks embarrassing individuals, causing people to resist participating in the initiative, private feedback could be the way to go. So when choosing how to provide feedback, leaders should carefully consider the organizational dynamics and the best way to achieve the desired outcomes.
4. Consider which stakeholder to focus on. The best way to achieve a desired outcome may be to focus on one group, not another, or it might be to focus on both. This might sound obvious, but most efforts to improve vaccination rates to date have focused on patients, not physicians — even though physicians are in a position to heavily influence patients.

Our study provides more evidence of the potential of behavioral science to improve health outcomes and reduce costs. It also shows the need to rigorously test assumptions when designing nudges. In the world of medical treatment evaluation, the randomized controlled experiment has long been the gold standard for evaluating medical treatments, but it is not often used to evaluate organizational practices in health care. Our study suggests that it should be.

RJ Niewoehner (PhD ’22) was a doctoral student in operations at UNC Kenan-Flagler, where Brad Staats is a professor of operations and faculty director of the Center for the Business of Health.

This article originally appeared in Harvard Business Review and is posted here with permission.