Antibiotic incentive program is the latest flashpoint in a global effort to curb resistance. Japan’s small, targeted payments to clinics that avoid unnecessary prescriptions have reduced use, but whether a similar approach could translate to the U.S. is an open question, according to physicians and policy experts.
Penicillin once symbolized a breakthrough against lethal infections. Decades of misuse and overuse have since fueled a “silent pandemic” of antibiotic resistance, experts say. Changing how clinicians prescribe and how patients expect to receive antibiotics is central to reversing that trend.
Similar pressures, different systems
In both Japan and the U.S., brief visits and limited rapid diagnostics leave room for uncertainty, and caregivers sometimes push for antibiotics even when viral illness is likely, research indicates. Clinicians say clear explanations often defuse requests for unnecessary drugs.
Japan’s policy addresses both sides. Pediatricians and ear, nose and throat specialists can claim about 800 yen, roughly 5 dollars, when they withhold antibiotics for certain conditions and document an explanation to caregivers about appropriate use.
However, structural differences are stark. Japan’s national insurance system makes children’s care essentially free, and public trust in government and healthcare is comparatively high. The U.S. relies on a mix of private, subsidized and public coverage. Millions remain uninsured, and many insured patients face prior authorization, denials and other barriers that can disrupt care and fuel frustration. Japan can roll out uniform incentives nationwide. The U.S. cannot.
Hesitations from U.S. doctors
Japanese clinicians were comfortable with modest add-on fees, which are common there and set by the national fee schedule. Similar tools in Japan have steered use of cheaper biosimilars and improved care for hip fractures and painful periods.
In the U.S., reimbursement is fragmented across public programs and private plans. Some American clinicians think a version could help. A pediatric ENT noted that physicians already face financial pressure from patient satisfaction metrics and that tying payments to stewardship might matter, though implementation would be difficult with many payers. Others called the concept unethical, warning that patients could suspect cost-cutting motives or that insurers might overreach and conflict with clinical guidelines. Some worried about underprescribing if money is on the line.
I do not believe that financial incentives should dictate clinical practice.
Dr. Erik Blutinger, emergency medicine physician for the Mount Sinai Health System
Several clinicians emphasized the need for safeguards to prevent undertreatment and to ensure alignment with evidence.
How incentives work in the U.S.
Many U.S. providers already face high-level stewardship incentives rather than case-by-case payments. Health plans use the Healthcare Effectiveness Data and Information Set to assess quality, including measures that track antibiotic use for typically viral conditions such as upper respiratory infections, sore throat and bronchitis. Some payers boost reimbursement when scores improve, though this is not universal.
These arrangements fit under value-based care, which rewards outcomes and cost control instead of volume. Medicare has its own approach that folds antibiotic metrics, including for upper respiratory infections, into a composite score that can raise or lower payment. Medicaid, which covers nearly half of U.S. children, lacks a direct equivalent but can also link reimbursement to quality metrics. Even as value-based care expands, fee-for-service remains dominant and some clinicians remain skeptical of accountability for outcomes beyond their control.
“You have to have some sort of guardrail”
Many U.S. doctors bristled at direct, per-visit payments tied to withholding prescriptions. Several cited low trust in insurers and concerns about underuse. One infectious-disease specialist contrasted Japan’s government-led culture of safety with U.S. payer priorities that may focus on finances, calling insurer-driven nonprescribing incentives unsettling without strict protections.
Japanese pediatricians, by contrast, voiced concern about overuse among peers and welcomed the add-on’s help to clinic finances.
Alternative approaches?
Given U.S. complexity, a carbon copy of Japan’s antibiotic incentive program appears unlikely. Clinicians suggested options that align with current infrastructure. Providers are already paid more when documenting certain quality items, such as body mass index and weight-management plans, under Medicare and HEDIS-linked measures that influence reimbursement.
Borrowing from Japan’s emphasis on communication, health systems could tie payment to documentation that clinicians educated caregivers about appropriate antibiotic use. Talking points could cover that many childhood illnesses are viral, that fever or green mucus does not prove a bacterial cause, that unnecessary antibiotics have side effects like diarrhea and can drive resistance, and that follow-up or watchful waiting may be appropriate. Electronic medical records could host standardized scripts and education prompts.
Clinics could reinforce conversations with take-home materials or links to vetted resources such as the American Academy of Pediatrics’ HealthyChildren.org. Trials indicate that educating parents about respiratory infections and antibiotics, and combining verbal with written information, can reduce demand for the drugs and lower prescribing. Interventions are especially effective when paired with provider-facing tools such as in-office materials, EMR guidance, local resistance data and audit-and-feedback reports comparing prescribing rates within a practice.
Targeting caregivers
Another path would reward caregivers directly for antibiotic education. Insurers, both private and public, already offer cash, gift cards or points for activities such as annual visits, screenings, step goals or health courses. Evidence suggests these programs can shift behavior, at least in the short term, with some longer-term gains shown in areas like smoking cessation.
The same model could fund short, interactive modules on antibiotics that explain what they treat, what they do not, what watchful waiting means and why resistance matters. Quizzes could trigger incremental rewards. Materials could mirror a Japanese app that outlines care for acute viral infections, which has been reported to reshape caregiver expectations and health system use.
Presumably, with that kind of continuing education of patients, they would perhaps seek antibiotics less and less and understand when they’re necessary.
Dr. Shruti Gohil, infectious-disease specialist with UCI Health
Advocates say this could trim unnecessary visits and prescriptions while supporting broader resistance goals.
Beyond pediatrics
Japan targeted pediatricians and ENTs due to documented overprescribing. In the U.S., urgent care centers appear to be a larger driver. Studies suggest urgent care settings are more likely than physician offices to issue antibiotics when not indicated. One analysis of millions of visits found prescribing for 15 percent of bronchitis cases, a diagnosis that rarely requires antibiotics.
Urgent care clinicians often have one-time encounters and report pressure to meet caregiver expectations. A national study found that more than half of pediatric urgent care providers altered care in response to parental requests, though two-thirds said families are open to education. That points to the value of prioritizing, and potentially incentivizing, counseling even in time-pressed environments.
Urgent care sites are frequently staffed by physician assistants and nurse practitioners alongside a supervising physician. Research has found PAs and NPs can be more likely than physicians to prescribe antibiotics for similar acute respiratory conditions, with the gap larger in pediatric visits, and with greater odds of inappropriate prescribing compared with pediatricians. Education and stewardship initiatives have historically focused on physicians, and training pathways for PAs and NPs vary, suggesting opportunities for targeted support.
Interventions may be most feasible in urgent care networks tied to hospital systems, which represent about 35 percent of centers and commonly use bonus metrics. Documentation metrics could require noting when rationale for not prescribing was discussed. A large Utah urgent care network coupled a compensation goal to reduce respiratory antibiotic use with clinician and patient education, EMR guidance and peer comparisons. Prescribing for respiratory conditions fell from 48 percent to 33 percent in one year and 26 percent the next.
Japan’s experience shows targeted incentives can help correct overuse. The same per-visit model may not fit the U.S., but aligning education, documentation, value-based metrics and caregiver engagement could deliver meaningful gains. As one CDC official noted, antimicrobial resistance is among the most urgent public health threats, and because outpatient prescribing is so common, even modest improvements can significantly improve safety and population health.
This report is for informational purposes and does not constitute medical advice.