PONE-D-24-33322Prospect Theory in Pay-for-Performance: Stated Preference Evidence from a U.S. SurveyPLOS ONE

Dear Dr. Khanderia,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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ACADEMIC EDITOR: Please refer to the work of the relevant authors instead of the website as a reference. Although the manuscript's title is Prospect Theory, the content is only about the losses and gains of the value function. Therefore, the title of the article does not fully reflect the content. Although one reviewer has rejected this manuscript and the other reviewer has made comments that would require rejecting the article, I would like to give you a chance to revise it, because the manuscript subject is important. 

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Please submit your revised manuscript by Dec 07 2024 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Partly

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: I Don't Know

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3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: No

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Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: Comments to authors:

This is a well done survey study providing estimates of how much money, in reward or penalty, clinicians think it will take to motivate them to increase vaccination rates. I have a few major concerns however, that I explain below.

1. Not really testing prospect theory. Many people say that behavioral economics shows that losses loom larger than gains. But that phenomenon is consistent with traditional economics, too, because of the downsloping of utility curves. I’ll explain with an extreme example.

a. Give me $500K and it will feel great

b. Take away $500k and I’ll be devastated. The loss looms much larger than the gain because it occurs on the steeper part of my utility/well-being curve.

c. Behavioral econ added a twist on this idea. The SAME outcomes, when occurring by gain v loss, feel different. Give people $10 dollars and then take it away and they will feel differently than if you take away $10 and give it back. They all end up in the same place, but that final place feels different depending on whether you got there through a loss or a gain. I’m probably not explaining this well, but let me illustrate by discussing your study more.

2. Your main finding shows that a carrot has to be larger then a stick to equally motivate people, at least hypothetically. A true test of prospect theory would look like this:

a. Group 1 receives salary $X this year (whatever that is) but can receive up to $Y more if they achieve high vaccination rates. Now we see how motivating $Y is.

b. Group 2 gets a pay raise, to $X + Y. But they can get penalize up to $Y for low vaccination rates.

c. These are identical situations, financially speaking, but prospect theory would predict that Group 2 will be more motivated.

d. Yous study did not test this design. It compared

i. Group 1 gets $X + $Y

ii. Group 2 gets $X - $Y

3. I suggest you revise the paper to clarify this issue. Your study is important, if the finding holds up in practice. But it is more about bonus vs penalty than about prospect theory

4. In a revision, I’d also like to see discussion of feasibility. It is one thing to say a penalty is more effective than a bonus, dollar for dollar. But would that be politically/socially feasible? That is a whole other bit of behavioral economics.

5. Final small comment/question: you say physicians had a larger difference, bonus vs penalty, than others. But was that in absolute terms or relative? Was the percent difference larger, or did they just need bigger bonuses and bigger penalties, with the same ratio of bonus/penalty as other people?

Thanks for this interesting study

Reviewer #2: 

The study represent a large-scale survey of a diverse range of US medical providers involved in the administration of HPV vaccines to children ages 9 through 12. Providers reported on to their professional backgrounds (e.g., medical training, practice type, healthcare system, etc.) and indicated the extent of annual bonus (i.e., gain frame) or annual income penalty (i.e., loss frame) that would motivate them increase their HPV vaccination rate in accordance with an unspecified annual vaccination target. Experimental conditions were grounded in Prospect Theory and assumed that “losses loom larger than gains,” that is, that bonuses would have to be substantially larger than penalties to motivate an increase in HPV vaccine delivery.

The manuscript at hand bears several noteworthy strengths. First, the study draws on a large sample of US medical providers (N = 2527) from different areas and different professional backgrounds. This makes for a particularly diverse and representative sample. It is also noteworthy that the authors considered a range of relevant covariates, such as prior experience with incentive schemes. The manuscript is accessibly written and easy to read and screen.

Despite its many merits, below, I suggest changes that I believe would further improve the quality of the manuscript and its contents. I invite the authors to consider implementing these changes where feasible.

MINOR ISSUES

- Page 2: Within the first paragraph, prospect theory and the term “loss frame” (as week as its implied counterpart, “gain frame”) are introduced but barely elaborated on. I find the introduction much too superficial for a lay reader. I recommend that the authors briefly describe the core assumptions of the theory and give an example of what a loss versus gain frame may look like. This would support understanding of the “losses loom twice as large” effect observed later in the results.

- Page 2: The introduction fails to explain why HPV vaccination rates may be so much lower than desired and to which degree medical providers have the opportunity to bring up that percentage if desired by these providers. This must be known to understand how an incentive scheme may bring up vaccination numbers (i.e., if it is not within providers’ individual means, then the scheme cannot be successful). For example, is it a question of having to inform/convince parents? A question of having insufficient staff or time slots to provide the vaccine?

- Page 2: Specify that for the bonus and penalty, financial/income-based ones are meant.

- Page 3: The abstract describes the response rate as 57%, the methods section describes it as “3 of 57%.” It is not clear what these numbers, particularly the 3, correspond to – could this be clarified?

- Page 3: Specify US dollars are meant.

- Page 7: I find the following sentence hard to interpret, can this be reformulated? “First, P4P programs [should this be ‘program’?] participants may bend their attention closer to process adherence rather than care optimization”.

- The formatting of tables is very inconsistent.

MAJOR ISSUES

- Limitations: Based on the instructions on page 3, the scenario did not specify an absolute target rate (e.g., x children per week/year) or a relative one (e.g., +10% more children in a week/year than at the moment). Given that the number of vaccinations administered or possibilities to do so will differ considerably by participant, participants’ perception of the feasibility of an uncertain, potential target likely biased their responses. It should be noted as a limitation that it is not known what target participants may have thought of, or how a more certain target (e.g., + 10%, which would still allow for differences in current vaccination numbers between participants) would have influenced the results.

- Limitations: Table 1 indicates that around 30% of the sample sees as few as 0 children in the relevant age range per week. This suggests that a considerable percentage of the sample is rarely in a position to administer HPV vaccines and should be identified as a limitation. This variable also appears absent as a control for the regressions reported in Table 4, although many others are included as covariates. The authors should either justify the omission of this variable from the analysis or re-run the regression with this variable included as a covariate. Furthermore, the authors may want to add an appendix in which they re-run the core analyses without all of the participants who see 0-9 children of the right age per week, as these participants may simply not be a good fit for the sample population.

- Limitations: Although many demographic/training-related covariates are included, two core covariates – income and a measure of trait loss aversion or similar concept relevant to prospect theory – were not assessed. Both seem highly relevant to the extent of bonus/penalty tolerated. I would note that future studies would benefit from their inclusion.

- Analyses: I find the statistical approach taken – many stratified t-tests, followed by regressions – not ideal, as it unnecessarily inflates the numbers of tests run. It strikes me as a more resource-efficient approach to simply run progressively more comprehensive regressions (starting with just the condition as IV and adding additional predictors to avoid the need for individual t-tests). Alternatively, the number of some tests could be halved by making use of using ANOVAs (e.g., an ANOVA with condition as one factor and experience as a second factor, rather than running separate tests for people with and without experience). I would, however, agree that for the reader, the inclusion of USD sums and differences in the results reporting is helpful and should be maintained when comparing groups.

Reviewer #3: While I very much liked and am excited by the premise of this work, I paused my review quickly after noticing the extremely casual effort put into the writing, study development, and analyses. This is a major topic with real-world consequences, but it has been written with almost no depth in the review or uses of information. There are 15 references, which is not alone an indication of quality, but when you see the casual statements made throughout the article that lack evidentiary backing, it raises a massive amount of concern about the rigor of the work itself. I would only consider this article if it was reapproached as a serious literature contribution, with extensive but concise statements about there it fits, what work it builds from, and much stronger technical acumen in the description of concepts (the pop psychology descriptions of loss aversion, prospect theory, etc. are really concerning).

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Reviewer #3: No

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PONE-D-24-33322R1Gain vs loss framing in pay-for-performance: Stated preference evidence from a U.S. surveyPLOS ONE

Dear Dr. Trogdon,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

ACADEMIC EDITOR:  We can see that in the main text, some references changed numbers, but in the reference section, this change is not mentioned through tracking. We would be pleased if you revised the manuscript, taking into account the first referee's evaluation.

Please submit your revised manuscript by Feb 19 2025 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org . When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

• A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.
• A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.
• An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

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We look forward to receiving your revised manuscript.

Kind regards,

Hatime Kamilcelebi

Academic Editor

PLOS ONE

Journal Requirements:

Please review your reference list to ensure that it is complete and correct. If you have cited papers that have been retracted, please include the rationale for doing so in the manuscript text, or remove these references and replace them with relevant current references. Any changes to the reference list should be mentioned in the rebuttal letter that accompanies your revised manuscript. If you need to cite a retracted article, indicate the article’s retracted status in the References list and also include a citation and full reference for the retraction notice.

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Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1: (No Response)

Reviewer #2: (No Response)

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2. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

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3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: I Don't Know

Reviewer #2: Yes

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4. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

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5. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

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6. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1:  The revision was responsive and well done. With one exception, and that might be my fault. I explained on the first review that this study did not test gain v loss framing. The authors responded by dropping reference to prospect theory. But I think it is still a mistake to call this gain vs loss framing. That language is more appropriate when we are comparing to identical situations but merely framing them differently. You like a surgery with a 90% survival rate better than one with a 10% mortality rate, even those are two ways of framing the same thing.

In this study, the gain v loss conditions are not the same intervention with a different framing. They are different interventions. Better language would be something that emphasizes the relative impact of carrots vs sticks, of gains vs losses; but you should emphasize, so readers don’t make the same mistake, that you did not test gain v loss framing.

If that isn’t clear, I’m happy to elaborate.

Reviewer #2:  Dear Dr. Kamilcelebi,

Thank you for this renewed opportunity to review the article PONE-D-24-33322R1, now titled “Gain vs loss framing in pay-for-performance: Stated preference evidence from a U.S. survey”.

I appreciate the authors’ thorough responses to all editor and reviewer comments made and believe the manuscript has improved substantially from the revisions. Below, I offer my responses to these revisions made by the research team (omitting the original reviewer and editor comments). Beyond those, I have no additional comments beyond noting minor typos/inconsistencies in the newly-added sections (e.g., “loss framed” instead of “loss-framed”, p. 13).

1. We have updated citations to cite the underlying authors rather than websites.

Response to 1: I apologize but I cannot see where these changes have taken place because there are no tracked changes concerning the reference list. I can see that in the main text, some references changed numbers, but cannot verify whether citations now focus on authors rather than websites. I trust this is the case.

2. We have updated the title […].

Response to 2: I approve of this change.

3. […] we updated the title and revised the Introduction and Discussion to remove references to prospect theory as motivation for the paper. Instead, we now focus on using gain vs loss frames in P4P and cite traditional economic utility theory to motivate the hypothesis (pp. 3-4, 11).

Response to 3: I approve of this change.

4. We added a paragraph in the Discussion that focuses on feasibility of loss frames for P4P in practice. [..]

Response to 4: I approve of this change.

5. […] we added a sentence noting that, for the training categories with significant differences between the gain (bonus) and loss (penalty) frame, the relative ratio of amounts were generally similar and between 1.86 and 2.

Response to : I approve of this change.

6. […] Instead, we now focus on using gain vs loss frames in P4P and cite traditional economic utility theory to motivate the hypothesis (pp. 3-4, 11).

Response to 6: I approve of this change.

7. [..] We added a section describing current barriers to HPV vaccination and emphasizing the crucial role that provider recommendations play in HPV vaccination. […]

Response to 7: I approve of this change; this addition very nicely provided plausible rationale for the present experiment.

8. We clarified at our first mention of bonuses and penalties that these refer to financial

bonuses and penalties. […]

Response 8: This has been clarified.

9. […] We are reporting their Response Rate #3. We capitalized the term to make it more obvious that it refers to a proper noun/definition.

Response to 9: This has been clarified.

10. We now define our currency as US dollars.[…]

Response to 10: This has been clarified.

11. […] we removed the sentence from the paper.

Response to 11: I approve of this change.

12. We updated all tables and formatted consistently.

Response to 12: This has improved.

13. […] , we followed the reviewers suggestion and added this to the limitations section. […]

Response to 13: This has improved.

14. While roughly 30% of the sample saw 0-9 children aged 9-12 in a typical week, only 33

respondents (1.3%) reported seeing zero children in a typical week. We have

addressed this in two sensitivity analyses. First, when we control for covariates listed in Table 1, we do include the“number of children ages 9-12 seen in typical week”

variable (see Supplemental Table 1). Second, we estimated our main analyses

removing the 33 respondents who reported seeing zero children aged 9-12 in a typical

week (Supplemental Table 2). In both analyses, the results were not meaningfully

different from our main analysis (p. 11).

Response to 14: I appreciate this helpful clarification and the changes made.

15. […] we followed the reviewer’s suggestion and added this to the limitations section. New text (p. 13): “Similarly, we did not observe respondents’ income or risk aversion, which would be relevant to the extent of bonus or penalty required to motivate action. In our design, we rely on the randomization of the gain vs loss frame to mitigate any bias in the analysis of the difference in responses. In other words, we expect that, like our measured covariates (Table 1), imagined P4P details, income and risk aversion will be balanced across the gain and loss frame samples and, therefore, not correlated with the treatment of interest. Future research would benefit from direct measurement of these factors.”

Response to 15: I approve of this change.

16. […] We now use linear regression with robust standard errors for all hypothesis tests. Model 1 includes only the randomized frame (gain vs loss) as the explanatory variable. Model 2 adds rurality fully interacted with gain/loss frame. Model 3 includes the gain/loss frame fully interacted with an indicator for experience with incentives. Finally, Model 4 includes the gain/loss frame fully interacted with indicators for respondents’ training. We use Stata’s“margins” commands to recover predicted (expected) incentive outcomes and incremental differences between the gain and loss frames by levels of the stratifying variables.

Response to 16: I approve of this change.

17. Based on this Reviewer’s comments and those from the other Reviewers, we have removed the focus on prospect theory as a motivator and now focus on the practical issue of designing P4P’s incentives as gain or losses. We cite traditional economic utility theory to motivate the hypothesis that the level of incentives needed to motivate action could be smaller when delivered as penalties (pp. 3-4, 11). As for where this paper fits into the broader literature, we updated our Introduction to include additional citations and context, nearly doubling the total number of citations (pp. 3-4). In brief, there is very little peer-reviewed evidence regarding P4P incentives for HPV vaccination, which is where we see the main contribution of this paper. The existing evidence on P4P for other vaccinations has generally not compared bonus (gain) vs penalty (loss) schemes.

Response to 17: I approve of this change.

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Reviewer #1: Yes:  Peter Ubel

Reviewer #2: Yes:  Julia Nolte

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Gains vs Losses in Pay-for-Performance: Stated Preference Evidence from a U.S. Survey

PONE-D-24-33322R2

Dear Dr. Trogdon,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Hatime Kamilcelebi

Academic Editor

PLOS ONE