Educational attainment affects the diagnostic time in type 2 diabetes mellitus and the mortality risk of those enrolled in the diabetes pay-for-performance program

Most patients are diagnosed as having diabetes only after experiencing diabetes complications. Educational attainment might have a positive relationship with diabetes prognosis. The diabetes pay-for-performance (P4P) program-providing comprehensive, continuous medical care-has improved diabetes prognosis in Taiwan. This retrospective cohort study investigated how educational attainment affects the presence of diabetes complications at diabetes diagnosis and mortality risk in patients with diabetes enrolled in the P4P program. From the National Health Insurance Research Database, we identified patients aged >45 years who had received a new diagnosis of type 2 diabetes during 2002-2015; they were followed up until the end of 2017. We next used logistic regression analysis to explore whether the patients with different educational attainments had varied diabetic complication risks at diabetes diagnosis. The Cox proportional hazard model was employed to examine the association of different educational attainments in people with diabetes with mortality risk after their enrollment in the P4P program. The results indicated that as educational attainment increased, the risk of diabetes complications at type 2 diabetes diagnosis decreased gradually. When type 2 diabetes with different educational attainments joined the P4P program, high school education had the highest effect on reducing mortality risk; however, those with ≤ 6th grade education had the lowest impact.

Acquisition of Urology Practices by Private Equity Firms and Performance in the Merit-based Incentive Payment System

INTRODUCTION

Private equity is increasingly engaged in the acquisition of urology practices. The implications of strategies to enhance practice value deployed by these firms for patients are unclear.

METHODS

We conducted a retrospective study of urologist performance in the MIPS (Merit-based Incentive Payment System) program for 2017 to 2020 using national Medicare data from the Quality Payment Program file. The primary outcome was the overall MIPS score. Secondary outcomes included MIPS component scores (ie, quality, interoperability, improvement activities, cost) and the percentage of urologists receiving a bonus payment. Generalized estimating equations were used to estimate the relationship between private equity acquisition and outcomes using a difference-in-differences framework.

RESULTS

Between 2017 and 2020, 181 urologists were in a urology practice acquired by private equity with MIPS data available the year before and after acquisition. Compared to urologists in practices not acquired by private equity, those in acquired practices had worse overall MIPS performance after acquisition (difference-in-differences estimate, -14 points, P = .04). The decrease in the overall score was driven by worse performance in the quality score (difference-in-differences estimate, -28 points, P < .001). Finally, acquisition resulted in a decrease in the percentage of urologists receiving bonus payments (difference-in-differences estimate, -43%, P < .001).

CONCLUSIONS

Private equity acquisition of urology practices was associated with significantly lower MIPS performance. As private equity acquisition of urology practices becomes more prevalent, key stakeholders should ensure that the quality of patient care is maintained and that the involvement of for-profit entities in health care is being made transparent to patients.

Examining the Long-term Spillover Effects of a Pay-for-Performance Program in a Healthcare System That Lacks Referral Arrangements

BACKGROUND

Several studies have examined the intended effects of pay-for-performance (P4P) programs, yet little is known about the unintended spillover effects of such programs on intermediate clinical outcomes. This study examines the long-term spillover effects of a P4P program for diabetes care.

METHODS

This study uses a nationwide population-based natural experimental design with a 3-year follow-up period under Taiwan's universal coverage healthcare system. The intervention group consisted of 7688 patients who enrolled in the P4P program for diabetes care in 2017 and continuously participated in the program for three years. The comparison group was selected by propensity score matching (PSM) from patients seen by the same group of physicians. Each patient had four records: one pertaining to one year before the index date of the P4P program and the other three pertaining to follow-ups spanning over the next three years. Generalized estimating equations (GEEs) with difference-in-differences (DID) estimations were used to consider the correlation between repeated observations for the same patients and patients within the same matched pairs.

RESULTS

Patients enrolled in the P4P program showed improvements in incentivized intermediate clinical outcomes that persisted over three years, including proper control of glycated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDL-C). We found a slight positive spillover effect of the P4P program on the control of non-incentivized triglyceride [TG]). However, we found no such effects on the non-incentivized high-density lipoprotein cholesterol (HDL-C) control.

CONCLUSION

The P4P program has achieved its primary goal of improving the incentivized intermediate clinical outcomes. The commonality in production among a set of activities is crucial for generating the spillover effects of an incentive program.

Impacts of performance-based financing on health system performance: evidence from the Democratic Republic of Congo

BACKGROUND

Health systems' weakness remains one of the primary obstacles towards achieving universal access to quality healthcare in low-income settings. Performance-based financing (PBF) programs have been increasingly used to increase access to quality care in LMICs. However, evidence on the impacts of these programs remains fragmented and inconclusive. We analyze the health system impacts of the PBF program in the Democratic Republic of the Congo (DRC), one of the largest such programs introduced in LMICs to date.

METHODS

We used a health systems perspective to analyze the benefits of PBF relative to unconditional financing of health facilities. Fifty-eight health zones in six provinces were randomly assigned to either a control group (28 zones) in which facilities received unconditional transfers or to a PBF program (30 zones) that started at the end of 2016. Follow-up data collection took place in 2021-2022 and included health facility assessments, health worker interviews, direct observations of consultations and deliveries, patient exit interviews, and household surveys. Using multivariate regression models, we estimated the impact of the program on 55 outcomes in seven health system domains: structural quality, technical process quality, non-technical process quality, service fees, facility management, providers' satisfaction, and service coverage. We used random-effects meta-analysis to generate pooled average estimates within each domain.

RESULTS

The PBF program improved the structural quality of health facilities by 4 percentage points (ppts) (95% CI 0.01-0.08), technical process quality by 5 ppts (0.03-0.07), and non-technical process by 2 ppts (0-0.04). PBF also increased coverage of priority health services by 3 ppts (0.02-0.04). Improvements were also observed for facility management (9 ppts, 0.04-0.15), service fee policies, and users' satisfaction with service affordability (14 ppts, 0.07-0.20). Service fees and health workers' satisfaction were not affected by the program.

CONCLUSIONS

The results suggest that well-designed PBF programs can lead to improvements in most health systems domains relative to comparable unconditional financing. However, the large persisting gaps suggest that additional changes, such as allocating more resources to the health system and reforming the human resources for health management, will be necessary in DRC to achieve the ambitious global universal health coverage and mortality goals.

TRIAL REGISTRATION

American Economics Association Trial registry AEARCTR-0002880.

Association of Pay-for-Performance Reimbursement With Clinical Quality for Minnesota Nursing Homes Residents

In 2016, Minnesota implemented a new pay-for-performance reimbursement scheme for Medicaid residents in nursing homes, known as Value-Based Reimbursement (VBR). This study seeks to understand whether there is an association between VBR and quality improvement. We use data from 2013 to 2019 including Centers for Medicare and Medicaid Services, Nursing Home Compare, and Long-term care Facts in the US. Using multivariate regression with commuting zone fixed effects, we compare five long-stay and two short-stay clinical quality metrics in Minnesota nursing homes to nursing homes bordering states, before and after VBR was implemented. We find minimal significant changes in quality in Minnesota nursing homes after VBR. Minnesota should reconsider its pay-for-performance efforts.

Choosing Wisely interventions to reduce antibiotic overuse in the safety net

OBJECTIVES

Physician pay-for-performance (P4P) programs frequently target inappropriate antibiotics. Yet little is known about P4P programs' effects on antibiotic prescribing among safety-net populations at risk for unintended harms from reducing care. We evaluated effects of P4P-motivated interventions to reduce antibiotic prescriptions for safety-net patients with acute respiratory tract infections (ARTIs).

STUDY DESIGN

Interrupted time series.

METHODS

A nonrandomized intervention (5/28/2015-2/1/2018) was conducted at 2 large academic safety-net hospitals: Los Angeles County+University of Southern California (LAC+USC) and Olive View-UCLA (OV-UCLA). In response to California's 2016 P4P program to reduce antibiotics for acute bronchitis, 5 staggered Choosing Wisely-based interventions were launched in combination: audit and feedback, clinician education, suggested alternatives, procalcitonin, and public commitment. We also assessed 5 unintended effects: reductions in Healthcare Effectiveness Data and Information Set (HEDIS)-appropriate prescribing, diagnosis shifting, substituting antibiotics with steroids, increasing antibiotics for ARTIs not penalized by the P4P program, and inappropriate withholding of antibiotics.

RESULTS

Among 3583 consecutive patients with ARTIs, mean antibiotic prescribing rates for ARTIs decreased from 35.9% to 22.9% (odds ratio [OR], 0.60; 95% CI, 0.39-0.93) at LAC+USC and from 48.7% to 27.3% (OR, 0.81; 95% CI, 0.70-0.93) at OV-UCLA after the intervention. HEDIS-inappropriate prescribing rates decreased from 28.9% to 19.7% (OR, 0.69; 95% CI, 0.39-1.21) at LAC+USC and from 40.9% to 12.5% (OR, 0.72; 95% CI, 0.59-0.88) at OV-UCLA. There was no evidence of unintended consequences.

CONCLUSIONS

These real-world multicomponent interventions responding to P4P incentives were associated with substantial reductions in antibiotic prescriptions for ARTIs in 2 safety-net health systems without unintended harms.

Plastic Surgeons and Equity: Are Merit-Based Incentive Payment System Scores Impacted by Minority Patient Caseload?

BACKGROUND

The Centers for Medicare and Medicaid Services introduced the Merit-based Incentive Payment System (MIPS) in 2017 to extend value-based payment to outpatient physicians. The authors hypothesized that the MIPS scores for plastic surgeons are impacted by the existing measures of patient disadvantage, minority patient caseload, and dual eligibility.

METHODS

The authors conducted a retrospective cohort study of plastic surgeons participating in Medicare and MIPS using the Physician Compare national downloadable file and MIPS scores. Minority patient caseload was defined as nonwhite patient caseload. The authors evaluated the characteristics of participating plastic surgeons, their patient caseloads, and their scores.

RESULTS

Of 4539 plastic surgeons participating in Medicare, 1257 participated in MIPS in the first year of scoring. The average patient caseload is 85% white, with racial/ethnicity data available for 73% of participating surgeons. In multivariable regression, higher minority patient caseload is associated with a lower MIPS score.

CONCLUSIONS

As minority patient caseload increases, MIPS scores decrease for otherwise similar caseloads. The Centers for Medicare and Medicaid Services must consider existing and additional measures of patient disadvantage to ensure equitable surgeon scoring.

Exploring patient perspectives: A qualitative inquiry into healthcare perceptions, experiences and satisfaction in Lebanon

BACKGROUND

Patient perspectives have received increasing importance within health systems over the past four decades. Measures of patient experience and satisfaction are commonly used. However, these measures do not capture all the information that is available through engaging with patients. An improved understanding of the various types of patient perspectives and the distinctions between them is needed. The lack of such knowledge limits the usefulness of including patient perspectives as components within pay-for-performance initiatives. This study aimed to explore patient perspectives on hospital care in Lebanon. It also aimed to contribute insights that may improve the national pay-for-performance initiative and to the knowledge on engaging patients towards person-centered health systems.

METHODS

We conducted a qualitative study using focus group discussions with persons recently discharged after hospitalization under the coverage of the Lebanese Ministry of Public Health. This study was implemented in 2017 and involved 42 participants across eight focus groups. Qualitative content analysis was used to analyze the information provided by participants.

RESULTS

Five overall themes supported by 17 categories were identified, capturing the meaning of the participants' perspectives: health is everything; being turned into second class citizens; money and personal connections make all the difference; wanting to be treated with dignity and respect; and tolerating letdown, for the sake of right treatment. The most frequently prioritized statement in a ranking exercise regarding patient satisfaction was regular contact with the patient's doctor.

CONCLUSIONS

Patient perspectives include more than what is traditionally incorporated in measures of patient satisfaction and experience. Patient valuing of health and their perceptions on each of the health system, and access and quality of care should also be taken into account. Hospital pay-for-performance initiatives can be made more responsive through a broader consideration of these perspectives. More broadly, health systems would benefit from wider engagement of patients. We propose a framework relating patient perspectives to value-based healthcare and health system performance.

Comparison of pay-for-performance (P4P) programs in primary care of selected countries: a comparative study

BACKGROUND

Pay for performance (P4P) schemes provide financial incentives or facilities to health workers based on the achievement of predetermined performance goals. Various P4P programs have been implemented around the world. There is a question of which model is suitable for p4p implementation to achieve better results. The purpose of this study is to compare pay for performance models in different countries.

METHODS

This is a descriptive-comparative study comparing the P4P model in selected countries in 2022. Data for each country are collected from reliable databases and are tabulated to compare their payment models. the standard framework of the P4P model is used for data analysis.

RESULTS

we used the standard P4P model framework to compare pay for performance programs in the primary care sector of selected countries because this framework can demonstrate all the necessary features of payment programs, including performance domains and measures, basis for reward or penalty, nature of the reward or penalty, and data reporting. The results of this study show that although the principles of P4P are almost similar in the selected countries, the biggest difference is in the definition of performance domains and measures.

CONCLUSIONS

Designing an effective P4P program is very complex, and its success depends on a variety of factors, from the socioeconomic and cultural context and the healthcare goals of governments to the personal characteristics of the healthcare provider. considering these factors and the general framework of the features of P4P programs are critical to the success of the p4p design and implementation.

Optimal Care for Kidney Health: Development of a Merit-based Incentive Payment System (MIPS) Value Pathway

The Merit-based Incentive Payment System (MIPS) is a mandatory pay-for-performance program through the Centers for Medicare & Medicaid Services (CMS) that aims to incentivize high-quality care, promote continuous improvement, facilitate electronic exchange of information, and lower health care costs. Previous research has highlighted several limitations of the MIPS program in assessing nephrology care delivery, including administrative complexity, limited relevance to nephrology care, and inability to compare performance across nephrology practices, emphasizing the need for a more valid and meaningful quality assessment program. This article details the iterative consensus-building process used by the American Society of Nephrology Quality Committee from May 2020 to July 2022 to develop the Optimal Care for Kidney Health MIPS Value Pathway (MVP). Two rounds of ranked-choice voting among Quality Committee members were used to select among nine quality metrics, 43 improvement activities, and three cost measures considered for inclusion in the MVP. Measure selection was iteratively refined in collaboration with the CMS MVP Development Team, and new MIPS measures were submitted through CMS's Measures Under Consideration process. The Optimal Care for Kidney Health MVP was published in the 2023 Medicare Physician Fee Schedule Final Rule and includes measures related to angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use, hypertension control, readmissions, acute kidney injury requiring dialysis, and advance care planning. The nephrology MVP aims to streamline measure selection in MIPS and serves as a case study of collaborative policymaking between a subspecialty professional organization and national regulatory agencies.

Hospital performance in a statewide commercial insurer episode-based incentive program

OBJECTIVES

To evaluate hospital performance and behaviors in the first 2 years of a statewide commercial insurance episode-based incentive pay-for-performance (P4P) program.

STUDY DESIGN

Retrospective cohort study of price- and risk-standardized episode-of-care spending from the Michigan Value Collaborative claims data registry.

METHODS

Changes in hospital-level episode spending between baseline and performance years were estimated during the program years (PYs) 2018 and 2019. The distribution and hospital characteristics associated with P4P points earned were described for both PYs. A difference-in-differences (DID) analysis compared changes in patient-level episode spending associated with program implementation.

RESULTS

Hospital-level episode spending for all conditions declined significantly from the baseline year to the performance year in PY 2018 (-$671; 95% CI, -$1113 to -$230) but was not significantly different for PY 2019 ($177; 95% CI, -$412 to $767). Hospitals earned a mean (SD) total of 6.3 (3.1) of 10 points in PY 2018 and 4.5 (2.9) of 10 points in PY 2019, with few significant differences in P4P points across hospital characteristics. The highest-scoring hospitals were more likely to have changes in case mix index and decreases in spending across the entire episode of care compared with the lowest-scoring hospitals. DID analysis revealed no significant changes in patient-level episode spending associated with program implementation.

CONCLUSIONS

There was little evidence for overall reductions in spending associated with the program, but the performance of the hospitals that achieved greatest savings and incentives provides insights into the ongoing design of hospital P4P metrics.

Impact of family networks on uptake of health interventions: evidence from a community-randomized control trial aimed at increasing HIV testing in South Africa

INTRODUCTION

While it is widely acknowledged that family relationships can influence health outcomes, their impact on the uptake of individual health interventions is unclear. In this study, we quantified how the efficacy of a randomized health intervention is shaped by its pattern of distribution in the family network.

METHODS

The "Home-Based Intervention to Test and Start" (HITS) was a 2×2 factorial community-randomized controlled trial in Umkhanyakude, KwaZulu-Natal, South Africa, embedded in the Africa Health Research Institute's population-based demographic and HIV surveillance platform (ClinicalTrials.gov # NCT03757104). The study investigated the impact of two interventions: a financial micro-incentive and a male-targeted HIV-specific decision support programme. The surveillance area was divided into 45 community clusters. Individuals aged ≥15 years in 16 randomly selected communities were offered a micro-incentive (R50 [$3] food voucher) for rapid HIV testing (intervention arm). Those living in the remaining 29 communities were offered testing only (control arm). Study data were collected between February and November 2018. Using routinely collected data on parents, conjugal partners, and co-residents, a socio-centric family network was constructed among HITS-eligible individuals. Nodes in this network represent individuals and ties represent family relationships. We estimated the effect of offering the incentive to people with and without family members who also received the offer on the uptake of HIV testing. We fitted a linear probability model with robust standard errors, accounting for clustering at the community level.

RESULTS

Overall, 15,675 people participated in the HITS trial. Among those with no family members who received the offer, the incentive's efficacy was a 6.5 percentage point increase (95% CI: 5.3-7.7). The efficacy was higher among those with at least one family member who received the offer (21.1 percentage point increase (95% CI: 19.9-22.3). The difference in efficacy was statistically significant (21.1-6.5 = 14.6%; 95% CI: 9.3-19.9).

CONCLUSIONS

Micro-incentives appear to have synergistic effects when distributed within family networks. These effects support family network-based approaches for the design of health interventions.

Prognostic Value of Pace Variability, a Novel 6MWT-Derived Feature, in Patients with Chronic Obstructive Pulmonary Disease

Purpose

The 6-minute walk test (6MWT) is often used to evaluate chronic obstructive pulmonary disease (COPD) patients' functional capacity, with 6-minute walk distance (6MWD) and related measures being linked to mortality and hospitalizations. This study investigates the prognostic value of pace variability, a significant indicator in sports medicine, during the 6MWT for COPD patients.

Patients and Methods

We retrospectively screened consecutive COPD patients who had been prospectively enrolled in a pay-for-performance program from January 2019 to May 2020 to determine their eligibility. Patient characteristics, including demographics, exacerbation history, and 6MWT data, were analyzed to investigate their potential associations with prognosis. The primary outcome was a composite of adverse events, including overall mortality or hospitalizations due to exacerbations during a 1-year follow-up period. To analyze the 6MWT data, we divided it into three 2-minute epochs and calculated the average walk speed for each epoch. We defined pace variability as the difference between the maximum and minimum average speed in a single 2-minute epoch, divided by the average speed for the entire 6-minute walk test.

Results

A total of 163 patients with COPD were included in the study, and 19 of them (12%) experienced the composite adverse outcome. Multivariable logistic regression analyses revealed that two predictors were independently associated with the composite outcome: % predicted 6MWD <72 (adjusted odds ratio [aOR] 7.080; 95% confidence interval [CI] 1.481-33.847) and pace variability ≥0.39 (aOR 9.444; 95% CI 2.689-33.170). Patients with either of these adverse prognostic features had significantly worse composite outcome-free survival, with both log-rank P values less than 0.005. Notably, COPD patients with both adverse features experienced an especially poor outcome after 1 year.

Conclusion

Patients with COPD who exhibited greater pace variability during the 6MWT had a significantly higher risk of overall mortality and COPD-related hospitalizations, indicating a worse prognosis.

The impact of health policies and the COVID-19 pandemic on exclusive breastfeeding in Chile during 2009-2020

In 2011, Chile added 12 mandatory extra weeks of maternity leave (ML). In January 2015, a pay-for-performance (P4P) strategy was included in the primary healthcare system, incorporating exclusive breastfeeding (EBF) promotion actions. The COVID-19 pandemic led to healthcare access difficulties and augmented household workloads. Our aim was to evaluate the effect of a 24-week ML, the P4P strategy, and COVID-19 on EBF prevalence, at 3 and 6 months in Chile. Aggregated EBF prevalence data from public healthcare users nationwide (80% of the Chilean population) was collected by month. Interrupted time series analyses were used to quantify changes in EBF trends from 2009 to 2020. The heterogeneity of EBF changes was assessed by urban/setting and across geographic settings. We found no effect of ML on EBF; the P4P strategy increased EBF at 3 months by 3.1% and 5.7% at 6 months. COVID-19 reduced EBF at 3 months by  - 4.5%. Geographical heterogeneity in the impact of the two policies and COVID-19 on EBF was identified. The null effect of ML on EBF in the public healthcare system could be explained by low access from public healthcare users to ML (20% had access to ML) and by an insufficient ML duration (five and a half months). The negative impact of COVID-19 on EBF should alert policy makers about the crisis's effect on health promotion activities.

Spillover effects of financial incentives for providers onto non-targeted patients: daycase surgery in English hospitals

BACKGROUND

Incentives for healthcare providers may also affect non-targeted patients. These spillover effects have important implications for the full impact and evaluation of incentive schemes. However, there are few studies on the extent of such spillovers in health care. We investigated whether incentives to perform surgical procedures as daycases affected whether other elective procedures in the same specialties were also treated as daycases.

DATA

8,505,754 patients treated for 92 non-targeted procedures in 127 hospital trusts in England between April and March 2016.

METHODS

Interrupted time series analysis of the probability of being treated as a daycase for non-targeted patients treated in six specialties where targeted patients were also treated and three specialties where they were not.

RESULTS

The daycase rate initially increased (1.04 percentage points, SE: 0.30) for patients undergoing a non-targeted procedure in incentivised specialties but then reduced over time. Conversely, the daycase rate gradually decreased over time for patients treated in a non-incentivised specialty.

DISCUSSION

Spillovers from financial incentives have variable effects over different activities and over time. Policymakers and researchers should consider the possibility of spillovers in the design and evaluation of incentive schemes.

Envisaging the job satisfaction and turnover intention among the young workforce: Evidence from an emerging economy

As the economy evolves and markets change after Covid-19, demand and competition in the labor market increase in China, and employees become increasingly concerned about their career opportunities, pay, and organizational commitment. This category of factors is often considered a key predictor of turnover intentions and job satisfaction, and it is important that companies and management have a good understanding of the factors that contribute to job satisfaction and turnover intentions. The purpose of this study was to investigate the factors that influence employees' job satisfaction and turnover intention and to examine the moderating role of employees' job autonomy. This cross-sectional study aimed to quantitatively assess the influence of perceived career development opportunity, perceived pay for performance, and affective organisational commitment on job satisfaction and turnover intention, as well as the moderating effect of job autonomy. An online survey, which involved 532 young workforce in China, was conducted. All data were subjected to partial least squares-structural equation modelling (PLS-SEM). The obtained results demonstrated the direct influence of perceived career development, perceived pay for performance, and affective organisational commitment on turnover intention. These three constructs were also found to have indirect influence on turnover intention through job satisfaction. Meanwhile, the moderating effect of job autonomy on the hypothesised relationships was not statistically significant. This study presented significant theoretical contributions on turnover intention in relation to the unique attributes of young workforce. The obtained findings may also benefit managers in their efforts of understanding the turnover intention of the workforce and promoting empowerment practices.

Exploring HPV vaccination policy and payer strategies for opportunities to improve uptake in safety-net settings

Introduction

We explored priorities and perspectives on health policy and payer strategies for improving HPV vaccination rates in safety-net settings in the United States.

Methods

We conducted qualitative interviews with policy and payer representatives in the greater Los Angeles region and state of New Jersey between December 2020 and January 2022. Practice Change Model domains guided data collection, thematic analysis, and interpretation.

Results

Five themes emerged from interviews with 11 policy and 8 payer participants, including: (1) payer representatives not prioritizing HPV vaccination specifically in incentive-driven clinic metrics; (2) policy representatives noting region-specific HPV vaccine policy options; (3) inconsistent motivation across policy/payer groups to improve HPV vaccination; (4) targeting of HPV vaccination in quality improvement initiatives suggested across policy/payer groups; and (5) COVID-19 pandemic viewed as both barrier and opportunity for HPV vaccination improvement across policy/payer groups.

Discussion

Our findings indicate opportunities for incorporating policy and payer perspectives into HPV vaccine improvement processes. We identified a need to translate effective policy and payer strategies, such as pay-for-performance programs, to improve HPV vaccination within safety-net settings. COVID-19 vaccination strategies and community efforts create potential policy windows for expanding HPV vaccine awareness and access.

The Role Of Financial Incentives In Biosimilar Uptake In Medicare: Evidence From The 340B Program

Biosimilar drugs-lower-cost alternatives to expensive biologic drugs-have the potential to slow the growth of US drug spending. However, rates of biosimilar uptake have varied across hospital outpatient providers. We investigated whether the 340B Drug Pricing Program, which offers eligible hospitals substantial discounts on drug purchases, inhibits biosimilar uptake. Almost one-third of US hospitals participate in the 340B program. Using a regression discontinuity design and two high-volume biologics with biosimilar competitors, filgrastim and infliximab, we estimated that 340B program eligibility was associated with a 22.9-percentage-point reduction in biosimilar adoption. In addition, 340B program eligibility was associated with 13.3 more biologic administrations annually per hospital and $17,919 more biologic revenue per hospital. Our findings suggest that the program inhibited biosimilar uptake, possibly as a result of financial incentives making reference drugs more profitable than biosimilar medications.

The Impact of Value-Based Payment Models for Networks of Care and Transmural Care: A Systematic Literature Review

INTRODUCTION

Value-based healthcare has potential for cost control and quality improvement. To assess this, we review the evidence on the impact of value-based payment (VBP) models in the context of networks of care (NOC) and transmural care.

METHODS

We used the PRISMA guidelines for this systematic literature review. We searched eight databases in July 2021. Subsequently, we conducted title and abstract and full-text screenings, and extracted information in an extraction matrix. Based on this, we assessed the evidence on the effects of VBP models on clinical outcomes, patient-reported outcomes/experiences, organization-related outcomes/experiences, and costs. Additionally, we reviewed the facilitating and inhibiting factors per VBP model.

FINDINGS

Among articles studying shared savings and pay-for-performance models, most outline positive effects on both clinical and cost outcomes, such as preventable hospitalizations and total expenditures, respectively. Most studies show no change in patient satisfaction and access to care when adopting VBP models. Providers' opinions towards the models are frequently negative. Transparency and communication among involved stakeholders are found to be key facilitating factors, transversal to all models. Additionally, a lack of trust is an inhibitor found in all VBP models, together with inadequate targets and insufficient incentives. In bundled payment and pay-for-performance models, complexity in the structure of the program and lack of experience in implementing required mechanisms are key inhibitors.

CONCLUSIONS

The overall positive effect on clinical and cost outcomes validates the success of VBP models. The mostly negative effects on organization-reported outcomes/experiences are corroborated by findings regarding providers' lack of awareness, trust, and engagement with the model. This may be justified by their exclusion from the design of the models, decreasing their sense of ownership and, therefore, motivation. Incentives, targets, benchmarks, and quality measures, if adequately designed, seem to be important facilitators, and if lacking or inadequate, they are key inhibitors. These are prominent facilitators and inhibitors for P4P and shared savings models but not as prominent for bundled payments. The complexity of the scheme and lack of experience are prominent inhibitors in all VBP models, since all require changes in several areas, such as behavioral, process, and infrastructure.

Creating a Business Case for Success

Health care is a highly competitive environment where managers must compete for finite resources. The Centers for Medicare & Medicaid Services-directed reimbursement models such as value-based purchasing and pay-for-performance heavily focused on quality improvement and nursing excellence are having a major impact on financial reimbursement for health care services in the United States. As such, nurse leaders must function in a business-focused environment where decisions regarding resource allocation are driven by quantifiable data, the potential return on investment, and the organization's ability to provide quality patient care in an efficient manner. It is imperative for nurse leaders to recognize the financial impact of potential additional revenue streams, as well as avoidable costs. Nurse leaders must also be skilled at translating the return on investment for nursing-centric programs and initiatives, often hidden in anecdotal terms and cost avoidance rather than revenue generation, to ensure appropriate resource allocation and budgetary assumptions. This article uses a case study framed within the business case to review a structured approach to operationalizing nursing-centric programs and highlights key strategies for success.

Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis

OBJECTIVE

To determine whether the withdrawal of the Quality and Outcomes Framework (QOF) scheme in primary care in Scotland in 2016 had an impact on selected recorded quality of care, compared with England where the scheme continued.

DESIGN

Controlled interrupted time series regression analysis.

SETTING

General practices in Scotland and England.

PARTICIPANTS

979 practices with 5 599 171 registered patients in Scotland, and 7921 practices with 56 270 628 registered patients in England in 2013-14, decreasing to 864 practices in Scotland and 6873 in England in 2018-19, mainly due to practice mergers.

MAIN OUTCOME MEASURES

Changes in quality of care at one year and three years after withdrawal of QOF financial incentives in Scotland at the end of the 2015-16 financial year for 16 indicators (two complex processes, nine intermediate outcomes, and five treatments) measured annually for financial years from 2013-14 to 2018-19.

RESULTS

A significant decrease in performance was observed for 12 of the 16 quality of care indicators in Scotland one year after QOF was abolished and for 10 of the 16 indicators three years after QOF was abolished, compared with England. At three years, the absolute percentage point difference between Scotland and England was largest for recording (by tick box) of mental health care planning (-40.2 percentage points, 95% confidence interval -45.5 to -35.0) and diabetic foot screening (-22.8, -33.9 to -11.7). Substantial reductions were, however, also observed for intermediate outcomes, including blood pressure control in patients with peripheral arterial disease (-18.5, -22.1 to -14.9), stroke or transient ischaemic attack (-16.6, -20.6 to -12.7), hypertension (-13.7, -19.4 to -7.9), diabetes (-12.7, -15.0 to -12.4), or coronary heart disease (-12.8, -14.9 to -10.8), and for glycated haemoglobin control in people with HbA_1c levels ≤75 mmol/mol (-5.0, -8.4 to -1.5). No significant differences were observed between Scotland and England for influenza immunisation and antiplatelet or anticoagulant treatment for coronary heart disease three years after withdrawal of incentives.

CONCLUSION

The abolition of financial incentives in Scotland was associated with reductions in recorded quality of care for most performance indicators. Changes to pay for performance should be carefully designed and implemented to monitor and respond to any reductions in care quality.

Does the implementation of pay-for-performance indicators improve the quality of healthcare? First results in France

Background

Pay-for-performance (P4P) models are intended to promote quality of care in both hospitals and primary care settings. They are considered as a means of changing medical practices, particularly in primary care.

Objectives

The first objective of this study was to assess how performance indicators changed over time, measured through “Remuneration on Public Health Objectives” (ROSP) scores, between 2017 and 2020 in a large French region (Grand Est region), and to compare this evolution in the rural vs. urban areas of the region. The second objective was to focus on the area with the least improvement in ROSP scores and to investigate whether the scores and the available sociodemographic characteristics of the area were associated.

Methods

First, we measured the evolution over time of P4P indicators (i.e., ROSP scores) obtained from the regional health insurance system, for GP practices in the Grand Est region between 2017 and 2020. We then compared the scores between the Aube Department and the rest of the region (urban areas). To address the second objective, we focused on the area found to have the least improvement in indicators to investigate whether there was a relationship between ROSP score and sociodemographic characteristics.

Results

More than 40,000 scores were collected. We observed an overall improvement in scores over the study period. The urban area (Grand Est region minus the Aube) scored better than the rural area (Aube) for chronic disease management [median 0.91 (0.84–0.95) vs. 0.90(0.79–0.94), p &lt; 0.001] and prevention [median 0.36 (0.22–0.45) vs. 0.33 (0.17–0.43), p &lt; 0.001], but not for efficiency, where the rural area (Aube) performed better [median 0.67(0.56–0.74) vs. 0.69 (0.57–0.75 in the rest of the Grand Est region, p = 0.004]. In the rural area, we found no significant association between ROSP scores and sociodemographic characteristics, except for extreme rurality in some sub-areas.

Conclusions

At the regional level, the overall improvement in scores observed between 2017 and 2020 suggests that the implementation of ROSP indicators have improved the quality of care, particularly in urban areas. These results also suggest that efforts should be focused on rural areas, which already had the lowest scores at the start of the P4P program.

Discontinuation of performance-based financing in primary health care: impact on family planning and maternal and child health

Performance-based financing (PBF) is advocated as an effective means to improve the quality of care by changing healthcare providers' behavior. However, there is limited evidence on its effectiveness in low- and middle-income countries and on its implementation in primary care settings. Evidence on the effect of discontinuing PBF is even more limited than that of introducing PBF schemes. We estimate the effects of discontinuing PBF in Egypt on family planning, maternal health, and child health outcomes. We use a difference-in-differences (DiD) model with fixed effects, exploiting a unique dataset of six waves of spatially constructed facility-level health outcomes. We find that discontinuing performance-based incentives to providers had a negative effect on the knowledge of contraceptive methods, iron supplementation during pregnancy, the prevalence of childhood acute respiratory infection, and, more importantly, under-five child mortality, all of which were indirectly targeted by the PBF scheme. No significant effects are reported for directly targeted outcomes. Our findings suggest that PBF can induce permanent changes in providers' behavior, but this may come at the expense of non-contracted outcomes.

A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks

Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism.

CONTEXT

Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers.

METHODS

To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research.

FINDINGS

The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity.

CONCLUSIONS

The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.