Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues

Pharmaceutical policies: effects of financial incentives for prescribers

BACKGROUND

The proportion of total healthcare expenditures spent on drugs has continued to grow in countries of all income categories. Policy-makers are under pressure to control pharmaceutical expenditures without adversely affecting quality of care. Financial incentives seeking to influence prescribers' behaviour include budgetary arrangements at primary care and hospital settings (pharmaceutical budget caps or targets), financial rewards for target behaviours or outcomes (pay for performance interventions) and reduced benefit margin for prescribers based on medicine sales and prescriptions (pharmaceutical reimbursement rate reduction policies). This is the first update of the original version of this review.

OBJECTIVES

To determine the effects of pharmaceutical policies using financial incentives to influence prescribers' practices on drug use, healthcare utilisation, health outcomes and costs (expenditures).

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (searched 29/01/2015); MEDLINE, Ovid SP (searched 29/01/2015); EMBASE, Ovid SP (searched 29/01/2015); International Network for Rational Use of Drugs (INRUD) Bibliography (searched 29/01/2015); National Health Service (NHS) Economic Evaluation Database (searched 29/01/2015); EconLit - ProQuest (searched 02/02/2015); and Science Citation Index and Social Sciences Citation Index, Institute for Scientific Information (ISI) Web of Knowledge (citation search for included studies searched 10/02/2015). We screened the reference lists of relevant reports and contacted study authors and organisations to identify additional studies.

SELECTION CRITERIA

We included policies that intend to affect prescribing by means of financial incentives for prescribers. Included in this category are pharmaceutical budget caps or targets, pay for performance and drug reimbursement rate reductions and other financial policies, if they were specifically targeted at prescribing or drug utilisation. Policies in this review were defined as laws, rules, regulations and financial and administrative orders made or implemented by payers such as national or local governments, non-government organisations, private or social insurers and insurance-like organisations. One of the following outcomes had to be reported: drug use, healthcare utilisation, health outcomes or costs. The study had to be a randomised or non-randomised trial, an interrupted time series (ITS) analysis, a repeated measures study or a controlled before-after (CBA) study.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed eligibility for inclusion of studies and risks of bias using Cochrane Effective Practice and Organisation of Care (EPOC) criteria and extracted data from the included studies. For CBA studies, we reported relative effects (e.g. adjusted relative change). The review team re-analysed all ITS results. When possible, the review team also re-analysed CBA data as ITS data.

MAIN RESULTS

Eighteen evaluations (six new studies) of pharmaceutical policies from six high-income countries met our inclusion criteria. Fourteen studies evaluated pharmaceutical budget policies in the UK (nine studies), two in Germany and Ireland and one each in Sweden and Taiwan. Three studies assessed pay for performance policies in the UK (two) and the Netherlands (one). One study from Taiwan assessed a reimbursement rate reduction policy. ITS analyses had some limitations. All CBA studies had serious limitations. No study from low-income or middle-income countries met the inclusion criteria.Pharmaceutical budgets may lead to a modest reduction in drug use (median relative change -2.8%; low-certainty evidence). We are uncertain of the effects of the policy on drug costs or healthcare utilisation, as the certainty of such evidence has been assessed as very low. Effects of this policy on health outcomes were not reported. Effects of pay for performance policies on drug use and health outcomes are uncertain, as the certainty of such evidence has been assessed as very low. Effects of this policy on drug costs and healthcare utilisation have not been measured. Effects of the reimbursement rate reduction policy on drug use and drug costs are uncertain, as the certainty of such evidence has been assessed as very low. No included study assessed the effects of this policy on healthcare utilisation or health outcomes. Administration costs of the policies were not reported in any of the included studies.

AUTHORS' CONCLUSIONS

Although financial incentives are considered an important element in strategies to change prescribing patterns, limited evidence of their effects can be found. Effects of policies, including pay for performance policies, in improving quality of care and health outcomes remain uncertain. Because pharmaceutical policies have uncertain effects, and because they might cause harm as well as benefit, proper evaluation of these policies is needed. Future studies should consider the impact of these policies on health outcomes, drug use and overall healthcare expenditures, as well as on drug expenditures.

The complex remuneration of human resources for health in low-income settings: policy implications and a research agenda for designing effective financial incentives

BACKGROUND

Human resources for health represent an essential component of health systems and play a key role to accelerate progress towards universal health coverage. Many countries in sub-Saharan Africa face challenges regarding the availability, distribution and performance of health workers, which could be in part addressed by providing effective financial incentives.

METHODS

Based on an overview of the existing literature, the paper highlights the gaps in the existing research in low-income countries exploring the different components of health workers' incomes. It then proposes a novel approach to the analysis of financial incentives and delineates a research agenda, which could contribute to shed light on this topic.

FINDINGS

The article finds that, while there is ample research that investigates separately each of the incomes health workers may earn (for example, salary, fee-for-service payments, informal incomes, "top-ups" and per diems, dual practice and non-health activities), there is a dearth of studies which look at the health workers' "complex remuneration", that is, the whole of the financial incentives available. Little research exists which analyses simultaneously all revenues of health workers, quantifies the overall remuneration and explores its complexity, its multiple components and their features, as well as the possible interaction between income components. However, such a comprehensive approach is essential to fully comprehend health workers' incentives, by investigating the causes (at individual and system level) of the fragmentation in the income structure and the variability in income levels, as well as the consequences of the "complex remuneration" on motivation and performance. This proposition has important policy implications in terms of devising effective incentive packages as it calls for an active consideration of the role that "complex remuneration" plays in determining recruitment, retention and motivation patterns, as well as, more broadly, the performance of health systems.

CONCLUSIONS

This paper argues that research focusing on the health workers' "complex remuneration" is critical to address some of the most challenging issues affecting human resources for health. An empirical research agenda is proposed to fill the gap in our understanding.

The effect of physician remuneration on regional variation in hospital treatments

We study medical practice variations for nine hospital treatments in the Netherlands. Our panel data estimations include various control factors and physician's role to explain hospital treatments in about 3,000 Dutch zip code regions over the period 2006-2009. In particular, we exploit the physicians' remuneration difference-fee-for-service (FFS) versus salary-to explain the effect of financial incentives on medical production. We find that utilization rates are higher in geographical areas where more patients are treated by physicians that are paid FFS. This effect is strong for supply sensitive treatments, such as cataracts and tonsillectomies, while we do not find an effect for non-supply sensitive treatments, such as hip fractures.

[Pay-for-performance in health care services: a review of the best evidence available]

Pay-for-performance (P4P) has been widely used around the world seeking to improve health outcomes, and in Brazil it is the basis of the National Program for Improving Access and Quality (PMAQ). The literature published between 1998 and January 2013 that evaluated the effectiveness of P4P to produce results or patterns of access and quality in health was scrutinized. A total of 138 studies, with the inclusion of a further 41 studies (14 systematic reviews, 07 clinical trials and 20 observational studies) were retrieved and analyzed Among the more rigorous studies, favorable conclusions for P4P were less frequent, whereas observational studies were more favorable to positive effects of P4P on the quality of, and access to, health services. Methodological limitations of observational studies may have contributed to these results, but the range of results is more linked to the conceptual and contextual aspects of the use of the P4P schemes reviewed, the heterogeneity of P4P models and results. P4P can be helpful in promoting the achievement of objectives in health care systems, especially in the short term and for specific actions requiring less effort of health care providers, but should be used with caution and with a rigorous planning model, also considering undesirable or adverse effects.

Practice-level quality improvement interventions in primary care: a review of systematic reviews

AIM

To present an overview of effective interventions for quality improvement in primary care at the practice level utilising existing systematic reviews.

BACKGROUND

Quality improvement in primary care involves a range of approaches from the system-level to patient-level improvement. One key setting in which quality improvement needs to occur is at the level of the basic unit of primary care--the individual general practice. Therefore, there is a need for practitioners to have access to an overview of the effectiveness of quality improvement interventions available in this setting.

METHODS

DESIGN

A tertiary evidence synthesis was conducted (a review of systematic reviews). A systematic approach was used to identify and summarise published literature relevant to understanding primary-care quality improvement at the practice level. Quality assessment was via the Critical Appraisal Skills Programme tool for systematic reviews, with data extraction identifying evidence of effect for the examined interventions.

SCOPE

Included reviews had to be relevant to quality improvement at the practice level and relevant to the UK primary-care context. Reviews were excluded if describing system-level interventions.

OUTCOME MEASURES

A range of measures across care structure, process and outcomes were defined and interpreted across the quality improvement interventions.

FINDINGS

Audit and feedback, computerised advice, point-of-care reminders, practice facilitation, educational outreach and processes for patient review and follow-up all demonstrated evidence of a quality improvement effect. Evidence of an improvement effect was higher where baseline performance was low and was particularly demonstrated across process measures and measures related to prescribing. Evidence was not sufficient to suggest that multifaceted approaches were more effective than single interventions.

CONCLUSION

Evidence exists for a range of quality improvement interventions at the primary-care practice level. More research is required to determine the use and impact of quality improvement interventions using theoretical frameworks and cost-effectiveness analysis.

Evaluation of a policy to strengthen case management and quality of diabetes care in general practice in Denmark

OBJECTIVES

To evaluate the utilization of a policy for strengthening general practitioner's case management and quality of care of diabetes patients in Denmark incentivized by a novel payment mode. We also want to elucidate any geographical variation or variation on the basis of practice features such as solo- or group practice, size of practice and age of the GP.

METHODS

On the basis registers encompassing reimbursement data from GPs and practice specific information about geographical location (region), type of practice (solo- or group-practice), size of practice (number of patients listed) and age of the GP were are able to determine differences in use of the policy in relation to the practice-specific information.

RESULTS

At the end of the study period (2007-2012) approximately 30% of practices have enrolled extending services to approximately 10% of the diabetes population. There is regional--as well as organizational differences between GPs who have enrolled and the national averages with enrolees being younger, from larger practices and with more patients listed.

CONCLUSIONS

Our study documents an organizationally and regionally varied and limited utilization with the overall incentive structure defined in the policy not strong enough to move the majority of GPs to change their way of delivering and financing care for patients with diabetes within a period of more than 5 years.

Quality check: does it matter for quality how you organize and pay for health care? A review of the international evidence

Health systems in high-income countries have experienced significant organizational and financial reforms over the last 25 years. The implications of these changes for the effectiveness of health care systems need to be examined, particularly in relation to their effects on the quality of health services (a pertinent issue in the United Kingdom in light of the Francis Report). Systematic review methodology was used to locate and evaluate published systematic reviews of quantitative intervention studies (experimental and observational) on the effects of health system organizational and financial reforms (system financing, funding allocations, direct purchasing arrangements, organization of service provision, and service integration) on quality of care in high-income countries. Nineteen systematic reviews were identified. The evidence on the payment of providers and purchaser-provider splits was inconclusive. In contrast, there is some evidence that greater integration of services can benefit patients. There were no relevant studies located relating to funding allocation reforms or direct purchasing arrangements. The systematic review-level evidence base suggests that the privatization and marketization of health care systems does not improve quality, with most financial and organizational reforms having either inconclusive or negative effects.

In place of fear: aligning health care planning with system objectives to achieve financial sustainability

The financial sustainability of publicly funded health care systems is a challenge to policymakers in many countries as health care absorbs an ever increasing share of both national wealth and government spending. New technology, aging populations and increasing public expectations of the health care system are often cited as reasons why health care systems need ever increasing funding as well as reasons why universal and comprehensive public systems are unsustainable. However, increases in health care spending are not usually linked to corresponding increases in need for care within populations. Attempts to promote financial sustainability of systems such as limiting the range of services is covered or the groups of population covered may compromise their political sustainability as some groups are left to seek private cover for some or all services. In this paper, an alternative view of financial sustainability is presented which identifies the failure of planning and management of health care to reflect needs for care in populations and to integrate planning and management functions for health care expenditure, health care services and the health care workforce. We present a Health Care Sustainability Framework based on disaggregating the health care expenditure into separate planning components. Unlike other approaches to planning health care expenditure, this framework explicitly incorporates population health needs as a determinant of health care requirements, and provides a diagnostic tool for understanding the sources of expenditure increase.

Evaluation of publicly financed and privately delivered model of emergency referral services for maternal and child health care in India

Background

Emergency referral services (ERS) are being strengthened in India to improve access for institutional delivery. We evaluated a publicly financed and privately delivered model of ERS in Punjab state, India, to assess its extent and pattern of utilization, impact on institutional delivery, quality and unit cost.

Methods

Data for almost 0.4 million calls received from April 2012 to March 2013 was analysed to assess the extent and pattern of utilization. Segmented linear regression was used to analyse month-wise data on number of institutional deliveries in public sector health facilities from 2008 to 2013. We inspected ambulances in 2 districts against the Basic Life Support (BLS) standards. Timeliness of ERS was assessed for determining quality. Finally, we computed economic cost of implementing ERS from a health system perspective.

Results

On an average, an ambulance transported 3–4 patients per day. Poor and those farther away from the health facility had a higher likelihood of using the ambulance. Although the ERS had an abrupt positive effect on increasing the institutional deliveries in the unadjusted model, there was no effect on institutional delivery after adjustment for autocorrelation. Cost of operating the ambulance service was INR 1361 (USD 22.7) per patient transported or INR 21 (USD 0.35) per km travelled.

Conclusion

Emergency referral services in Punjab did not result in a significant change in public sector institutional deliveries. This could be due to high baseline coverage of institutional delivery and low barriers to physical access. Choice of interventions for reduction in Maternal Mortality Ratio (MMR) should be context-specific to have high value for resources spent. The ERS in Punjab needs improvement in terms of quality and reduction of cost to health system.

Physician assistants and nurse practitioners perform effective roles on teams caring for Medicare patients with diabetes

One approach to the patient-centered medical home, particularly for patients with chronic illnesses, is to include physician assistants (PAs) and nurse practitioners (NPs) on primary care teams. Using Medicare claims and electronic health record data from a large physician group, we compared outcomes for two groups of adult Medicare patients with diabetes whose conditions were at various levels of complexity: those whose care teams included PAs or NPs in various roles, and those who received care from physicians only. Outcomes were generally equivalent in thirteen comparisons. In four comparisons, outcomes were superior for the patients receiving care from PAs or NPs, but in three other comparisons the outcomes were superior for patients receiving care from physicians only. Specific roles performed by PAs and NPs were associated with different patterns in the measure of the quality of diabetes care and use of health care services. No role was best for all outcomes. Our findings suggest that patient characteristics, as well as patients' and organizations' goals, should be considered when determining when and how to deploy PAs and NPs on primary care teams. Accordingly, training and policy should continue to support role flexibility for these health professionals.

Using data mining to detect health care fraud and abuse: a review of literature

Inappropriate payments by insurance organizations or third party payers occur because of errors, abuse and fraud. The scale of this problem is large enough to make it a priority issue for health systems. Traditional methods of detecting health care fraud and abuse are time-consuming and inefficient. Combining automated methods and statistical knowledge lead to the emergence of a new interdisciplinary branch of science that is named Knowledge Discovery from Databases (KDD). Data mining is a core of the KDD process. Data mining can help third-party payers such as health insurance organizations to extract useful information from thousands of claims and identify a smaller subset of the claims or claimants for further assessment. We reviewed studies that performed data mining techniques for detecting health care fraud and abuse, using supervised and unsupervised data mining approaches. Most available studies have focused on algorithmic data mining without an emphasis on or application to fraud detection efforts in the context of health service provision or health insurance policy. More studies are needed to connect sound and evidence-based diagnosis and treatment approaches toward fraudulent or abusive behaviors. Ultimately, based on available studies, we recommend seven general steps to data mining of health care claims.

Impact of state-specific Medicaid reimbursement and eligibility policies on receipt of cancer screening

BACKGROUND

Although state Medicaid programs cover cancer screening, Medicaid beneficiaries are less likely to be screened for cancer and are more likely to present with tumors of an advanced stage than are those with other insurance. The current study was performed to determine whether state Medicaid eligibility and reimbursement policies affect the receipt of breast, cervical, and colon cancer screening among Medicaid beneficiaries.

METHODS

Cross-sectional regression analyses of 2007 Medicaid data from 46 states and the District of Columbia were performed to examine associations between state-specific Medicaid reimbursement/eligibility policies and receipt of cancer screening. The study sample included individuals aged 21 years to 64 years who were enrolled in fee-for-service Medicaid for at least 4 months. Subsamples eligible for each screening test were: Papanicolaou test among 2,136,511 patients, mammography among 792,470 patients, colonoscopy among 769,729 patients, and fecal occult blood test among 753,868 patients. State-specific Medicaid variables included median screening test reimbursement, income/financial asset eligibility requirements, physician copayments, and frequency of eligibility renewal.

RESULTS

Increases in screening test reimbursement demonstrated mixed associations (positive and negative) with the likelihood of receiving screening tests among Medicaid beneficiaries. In contrast, increased reimbursements for office visits were found to be positively associated with the odds of receiving all screening tests examined, including colonoscopy (odds ratio [OR], 1.07; 95% confidence interval [95% CI], 1.06-1.08), fecal occult blood test (OR, 1.09; 95% CI, 1.08-1.10), Papanicolaou test (OR, 1.02; 95% CI, 1.02-1.03), and mammography (OR, 1.02; 95% CI, 1.02-1.03). Effects of other state-specific Medicaid policies varied across the screening tests examined.

CONCLUSIONS

Increased reimbursement for office visits was consistently associated with an increased likelihood of being screened for cancer, and may be an important policy tool for increasing screening among this vulnerable population.

All Things Being Equal: Does it Matter for Equity How You Organize and Pay for Health Care? A Review of the International Evidence

Over the last 25 years, the health care systems of most high-income countries have experienced extensive—usually market-based—organizational and financial reforms. The impact of these system changes on health equity has been hotly debated. Examining evidence from systematic reviews of the effects of health care system organizational and financial reforms will add empirical information to this debate, identify any evidence gaps, and help policy development. Systematic review methodology was used to locate and evaluate published systematic reviews of quantitative intervention studies (experimental and observational) of the effects on equity in health care access and/or health status of health care system organizational and financial reforms (system financing, funding allocations, direct purchasing arrangements, organization of service provision, and health and social care system integration) in high-income countries. Nine systematic reviews were identified. Private insurance and out-of-pocket payments as well as the marketization and privatization of services have either negative or inconclusive equity effects. The evidence base on the health equity effects of managed care programs or integrated partnerships between health and social services is inconclusive. There were no relevant studies located that related to resource allocation reforms. The systematic review-level evidence base suggests that financial and organizational health care system reforms have had either inconclusive or negative impacts on health equity both in terms of access relative to need and in terms of health outcomes.

Perceptions of Turkish Dentists of Their Professional Identity in a Market-Orientated System

This study explores the perceptions of Turkish dentists of their professional identity and of the effects of market orientation in dentistry. This phenomenological study used a qualitative approach using a group of Turkish dentists, who were selected based on the principle of maximum variation. Four focus groups and 31 in-depth interviews were conducted. Forty-nine dentists were interviewed using a semi-structured form. The data analysis yielded three themes: ( a) dentistry as a business; ( b) dentistry as a profession; and ( c) professional status of dentistry in the health care system and in the community. The participants' statements reflected that the dominance of market mechanisms in dentistry inevitably forces dentists to adopt the characteristics of a businessperson and prevents them from fulfilling the basic requirements of professionalism. All participants explained that with the transformation of the dental care market, dentists have become a cheap labor force and have lost their professional autonomy. Our study has confirmed previous reports pointing out the conflict between dentistry as a profession and dentistry as a commercial operation. The study also showed that in Turkey, as a country experiencing rapid reform processes, dentists' control over their professional practices and identities has decreased.

What determines providers' stated preference for the treatment of uncomplicated malaria?

As agents for their patients, providers often make treatment decisions on behalf of patients, and their choices can affect health outcomes. However, providers operate within a network of relationships and are agents not only for their patients, but also other health sector actors, such as their employer, the Ministry of Health, and pharmaceutical suppliers. Providers' stated preferences for the treatment of uncomplicated malaria were examined to determine what factors predict their choice of treatment in the absence of information and institutional constraints, such as the stock of medicines or the patient's ability to pay. 518 providers working at non-profit health facilities and for-profit pharmacies and drug stores in Yaoundé and Bamenda in Cameroon and in Enugu State in Nigeria were surveyed between July and December 2009 to elicit the antimalarial they prefer to supply for uncomplicated malaria. Multilevel modelling was used to determine the effect of financial and non-financial incentives on their preference, while controlling for information and institutional constraints, and accounting for the clustering of providers within facilities and geographic areas. 69% of providers stated a preference for artemisinin-combination therapy (ACT), which is the recommended treatment for uncomplicated malaria in Cameroon and Nigeria. A preference for ACT was significantly associated with working at a for-profit facility, reporting that patients prefer ACT, and working at facilities that obtain antimalarials from drug company representatives. Preferences were similar among colleagues within a facility, and among providers working in the same locality. Knowing the government recommends ACT was a significant predictor, though having access to clinical guidelines was not sufficient. Providers are agents serving multiple principals and their preferences over alternative antimalarials were influenced by patients, drug company representatives, and other providers working at the same facility and in the local area. Efforts to disseminate drug policy should target the full range of actors involved in supplying drugs, including providers, employers, suppliers and local communities.

Changes in the remuneration system for general practitioners: effects on contact type and consultation length

In The Netherlands, the remuneration system for GPs changed in 2006. Before the change, GPs received a capitation fee for publicly insured patients and fee for service (FFS) for privately insured patients. In 2006, a combined system was introduced for all patients, with elements of capitation as well as FFS. This created a unique opportunity to investigate the effects of the change in the remuneration system on contact type and consultation length. Our hypothesis was that for former publicly insured patients the change would lead to an increase in the proportion of home visits, a decrease in the proportion of telephone consultations and an increase in consultation length relative to formerly privately insured patients. Data were used from electronic medical records from 36 to 58 Dutch GP practices and from 532,800 to 743,961 patient contacts between 2002 and 2008 for contact type data. For consultation length, 1,994 videotaped consultations were used from 85 GP practices in 2002 and 499 consultations from 16 GP practices in 2008. Multilevel multinomial regression analysis was used to analyse consultation type. Multilevel logistic and linear regression analyses were used to examine consultation length. Our study shows that contact type and consultation length were hardly affected by the change in remuneration system, though the proportion of home visits slightly decreased for privately insured patients compared with publicly insured patients. Declaration behaviour regarding telephone consultations did change; GP practices more consistently declared telephone consultations after 2006.

The Effect of Market-Based Economic Factors on the Adoption of Orphan Drugs Across Multiple Countries

Orphan drugs are designed to treat rare disease. Multiple countries have approved regulations that support the creation of new orphan drugs. The regulations directly and indirectly affect orphan drug markets and contribute to classifying a country as being more or less market based. A more market-based country is recognized as functioning closest to free market principles, where the actions of supply, demand, and pricing operate with minimal government involvement. However, little information exists on how country market differences affect the adoption of these orphan drugs. This study argues that relationships exist between country market-based economic factors and the adoption of orphan drugs. This research uses a combination of qualitative and quantitative methods, drawing on orphan drug adoption of 13 marketed orphan drugs in France, Germany, Spain, the UK, and the US. Results show a statistically significant but negative relationship between the degree to which a country is market based and the adoption of orphan drugs. Results suggest that governments and regulators in less market-based countries support market factors that result in a more efficient delivery of orphan drug products to patients with rare diseases.

Payment systems and incentives in primary care: implications of recent reforms in Estonia and Romania

Since the early 1990s, major reform in healthcare has been adopted in former communist countries in Central and Eastern Europe. More than 20 years after, reform in healthcare still draws much interest from policy makers and academics alike. One of the dynamic components of reform has been the reform of payment systems in primary care. This article looks at recent developments in payment systems and financial incentives in Estonia and Romania. We conclude that finding the appropriate mix in paying and incentivizing primary care providers in a transitional context is no easy solution for healthcare policy makers who need to carefully weigh in the advantages and inherent problems of various payment arrangements. In a transitional, rapidly changing healthcare system and society, and a context of financial stringency, the theoretical effects of payment mechanisms may be more difficult to predict and manage than it is expected.

Accounting for variation in length of NICU stay for extremely low birth weight infants

OBJECTIVE

To develop a length of stay (LOS) model for extremely low birth weight (ELBW) infants.

STUDY DESIGN

We included infants from the California Perinatal Quality Care Collaborative with birth weight 401 to 1000 g who were discharged to home. Exclusion criteria were congenital anomalies, surgery and death. LOS was defined as days from admission to discharge. As patients who died or were transferred to lower level of care were excluded, we assessed correlation of hospital mortality rates and transfers to risk-adjusted LOS.

RESULTS

There were 2012 infants with median LOS 79 days (range 23 to 219). Lower birth weight, lack of antenatal steroids and lower Apgar score were associated with longer LOS. There was negligible correlation between risk-adjusted LOS and hospital mortality rates (r=0.0207) and transfer-out rates (r=0.121).

CONCLUSION

Particularly because ELBW infants have extended hospital stays, identification of unbiased and informative risk-adjusted LOS for these infants is an important step in benchmarking best practice and improving efficiency in care.

Acceptability of Quality Reporting and Pay for Performance among Primary Health Centers in Lebanon

Primary health care (PHC) is emphasized as the cornerstone of any health care system. Enhancing PHC performance is considered a strategy to enhance effective and equitable access to care. This study assesses the acceptability of and factors associated with quality reporting among PHC centers (PHCCs) in Lebanon. The managers of 132 Lebanese Ministry of Health PHCCs were surveyed using a cross-sectional design. Managers' willingness to report quality, participate in comparative quality assessments, and endorse pay-for-performance schemes was evaluated. Collected data were matched to the infrastructural characteristics and services database. Seventy-six percent of managers responded to the questionnaire, 93 percent of whom were willing to report clinical performance. Most expressed strong support for peer-performance comparison and pay-for-performance schemes. Willingness to report was negatively associated with the religious affiliation of centers and presence of health care facilities in the catchment area and favorably associated with use of information systems and the size of population served. The great willingness of PHCC managers to employ quality-enhancing initiatives flags a policy priority for PHC stakeholders to strengthen PHCC infrastructure and to enable reporting in an easy, standardized, and systematic way. Enhancing equity necessitates education and empowerment of managers in remote areas and those managing religiously affiliated centers.

Academic productivity and its relationship to physician salaries in the University of California Healthcare System

OBJECTIVES

To evaluate whether physicians with higher academic productivity, as measured by the number of publications in Scopus and the Scopus Hirsch index (h-index), earn higher salaries.

METHODS

This was a cross-sectional study. Participants were ophthalmologists, otolaryngologists, neurosurgeons, and neurologists classified as "top earners" (>$100,000 annually) within the University of California (UC) healthcare system in 2008. Bibliometric searches on Scopus were conducted to retrieve the total number of publications and Hirsch indices (h-index), a measure of academic productivity. The association between the number of publications and h-index on physicians' total compensation was determined with multivariate regression models after controlling for the four specialties (ophthalmology, otolaryngology, neurosurgery, and neurology), the five institutions (UC San Francisco, UC Los Angeles, UC San Diego, UC Irvine, and UC Davis), and academic rank (assistant professor, associate professor, and professor).

RESULTS

The UC healthcare system departments reported 433 faculty physicians among the four specialties, with 71.6% (n = 310) earning more than $100,000 in 2008 and classifying as top earners. After controlling for the specialty, institution, and ranking, there was a significant association between the number of publications on salary (P < 0.000001). Scopus number of publications and h-index were correlated (P < 0.001). Scopus h-index was of borderline significance in predicting physician salary (P = 0.12). Physicians with higher Scopus publications had higher total salaries across all four specialties. Every 10 publications were associated with a 2.40% increase in total salary after controlling for specialty, institution, rank, and chair.

CONCLUSIONS

Ophthalmologists, otolaryngologists, neurosurgeons, and neurologists in the UC healthcare system who are more academically productive receive greater remuneration.

Impact of pay-for-performance on management of diabetes: a systematic review

OBJECTIVES

To review and synthesize published evidence of pay-for-performance (P4P) effects on management of diabetes.

METHODS

Databases including Ovid MEDLINE, EMbase, PubMed, The Cochrane Library (Issue 3, 2012) were comprehensively searched for the effects of P4P programs in terms of patient outcomes and physician behaviors. Studies covering detailed data were included and synthesized. The quality of the body of evidence for each quality indicator was determined using Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system.

RESULTS

Among 742 identified articles, 12 interrupted time series studies, 7 controlled before-after studies, and 2 cross-sectional studies were included. Additionally, 12 studies were further included for quantitative analysis. Results of meta-analysis showed that P4P produced generally positive effects in most indicators (eg, patients with records of total cholesterol or blood pressure). However, these results were inconsistent. The percentage of patients with HbA1c ≤ 7% or 53 mmol/mol showed a pooled odds ratio of 0.98 in patients, but a pooled mean difference of 19.71% in the physician groups. The odds ratios of receiving tests/reaching an outcome level were also diverse in patients (odds ratios ranged from 0.98 to 3.32). Besides, process indicators had higher rates of improvement than outcome indicators.

CONCLUSIONS

P4P programs have variable impacts on patient outcomes of diabetes as well as physician behaviors, with various effects from negligible to strongly beneficial. Considering the low quality of the included studies, this conclusion should be cautiously interpreted.

Developing an active implementation model for a chronic disease management program

Background

Introduction and diffusion of new disease management programs in healthcare is usually slow, but active theory-driven implementation seems to outperform other implementation strategies. However, we have only scarce evidence on the feasibility and real effect of such strategies in complex primary care settings where municipalities, general practitioners and hospitals should work together. The Central Denmark Region recently implemented a disease management program for chronic obstructive pulmonary disease (COPD) which presented an opportunity to test an active implementation model against the usual implementation model. The aim of the present paper is to describe the development of an active implementation model using the Medical Research Council’s model for complex interventions and the Chronic Care Model.

Methods

We used the Medical Research Council’s five-stage model for developing complex interventions to design an implementation model for a disease management program for COPD. First, literature on implementing change in general practice was scrutinised and empirical knowledge was assessed for suitability. In phase I, the intervention was developed; and in phases II and III, it was tested in a block- and cluster-randomised study. In phase IV, we evaluated the feasibility for others to use our active implementation model.

Results

The Chronic Care Model was identified as a model for designing efficient implementation elements. These elements were combined into a multifaceted intervention, and a timeline for the trial in a randomised study was decided upon in accordance with the five stages in the Medical Research Council’s model; this was captured in a PaTPlot, which allowed us to focus on the structure and the timing of the intervention. The implementation strategies identified as efficient were use of the Breakthrough Series, academic detailing, provision of patient material and meetings between providers. The active implementation model was tested in a randomised trial (results reported elsewhere).

Conclusion

The combination of the theoretical model for complex interventions and the Chronic Care Model and the chosen specific implementation strategies proved feasible for a practice-based active implementation model for a chronic-disease-management-program for COPD. Using the Medical Research Council’s model added transparency to the design phase which further facilitated the process of implementing the program.

Trial registration: http://www.clinicaltrials.gov/(NCT01228708).

Paying physician group practices for quality: A statewide quasi-experiment

This article presents the results of a unique quasi-experiment of the effects of a large-scale pay-for-performance (P4P) program implemented by a leading health insurer in Washington state during 2001-2007. The authors received external funding to provide an objective impact evaluation of the program. The program was unique in several respects: (1) It was designed dynamically, with two discrete intervention periods-one in which payment incentives were based on relative performance (the "contest" period) and a second in which payment incentives were based on absolute performance compared to achievable benchmarks. (2) The program was designed in collaboration with large multispecialty group practices, with an explicit run-in period to test the quality metrics. Public reporting of the quality scorecard for all participating medical groups was introduced 1 year before the quality incentive payment program's inception, and continued throughout 2002-2007. (3) The program was implemented in stages with distinct medical groups. A control group of comparable group practices also was assembled, and difference-in-differences methodology was applied to estimate program effects. Case mix measures were included in all multivariate analyses. The regression design permitted a contrast of intervention effects between the "contest" approach in the sub-period of 2003-2004 and the absolute standard, "achievable benchmarks of care" approach in sub-period 2005-2007. Most of the statistically significant quality incentive program coefficients were small and negative (opposite to program intent). A consistent pattern of differential intervention impact in the sub-periods did not emerge. Cumulatively, the probit regression estimates indicate that neither the quality scorecard nor the quality incentive payment program had a significant positive effect on general clinical quality. Based on key informant interviews with medical leaders, practicing physicians, and administrators of the participating groups, the authors conclude that several factors likely combined to dampen program effects: (1) modest size of the incentive; (2) use of rewards only, rather than a balance of rewards and penalties; (3) targeting incentive payments to the group, thus potentially weakening incentive effects at the individual level.

Forgotten drugs: long-term prescriptions of thyroid hormones - a cross-sectional study

Background

Thyroid hormones are among the most prescribed drugs in Germany. Although iodine supply has been improving in the last decade, annual prescriptions for thyroid hormones are rising. The aim of this study was to provide prevalence of thyroid hormone prescribing and to explore reasons for thyroid hormone prescription in primary care settings.

Study design

A cross-sectional study.

Methods

Data collection took place in six general practitioner (GP) practices in Hesse, Germany. We used the records of six GP practices to estimate prevalence of thyroid hormone prescribing. All patients who received a prescription of the active ingredient levotyroxine during the preceding 3 months were mailed a study invitation. A proportion of the identified patients were interviewed. In addition, demographical data and all medical findings related to thyroid disease were recorded.

Results

On average, 9.2% (SD 4.6) of all patients from participating practices were taking thyroid hormones. The majority were female (82.5%). In 47.7% of the study participants, the GP’s diagnosis, according to their records, was nonexistent. In 13.6% of cases, the documentation of the diagnostic information was incomplete. While 25% of interviewed patients with high educational background initiated further diagnostic investigation, only 4.4% of the patients with lower education did so.

Conclusion

In the majority of patients treated with thyroid hormones, doctors had not documented the precise indication for prescription.

Moral hazard and supplier-induced demand: empirical evidence in general practice

Changes in cost sharing and remuneration system in the Netherlands in 2006 led to clear changes in financial incentives faced by both consumers and general practitioner (GPs). For privately insured consumers, cost sharing was abolished, whereas those socially insured never faced cost sharing. The separate remuneration systems for socially insured consumers (capitation) and privately insured consumers (fee-for-service) changed to a combined system of capitation and fee-for-service for both groups. Our first hypothesis was that privately insured consumers had a higher increase in patient-initiated GP contact rates compared with socially insured consumers. Our second hypothesis was that socially insured consumers had a higher increase in physician-initiated contact rates. Data were used from electronic medical records from 32 GP-practices and 35336 consumers in 2005-2007. A difference-in-differences approach was applied to study the effect of changes in cost sharing and remuneration system on contact rates. Abolition of cost sharing led to a higher increase in patient-initiated utilisation for privately insured consumers in persons aged 65 and older. Introduction of fee-for-service for socially insured consumers led to a higher increase in physician-initiated utilisation. This was most apparent in persons aged 25 to 54. Differences in the trend in physician-initiated utilisation point to an effect of supplier-induced demand. Differences in patient-initiated utilisation indicate limited evidence for moral hazard.

Impact of remuneration on guideline adherence: empirical evidence in general practice

BACKGROUND AND OBJECTIVE

Changes in the Dutch GP remuneration system provided the opportunity to study the effects of changes in financial incentives on the quality of care. Separate remuneration systems for publicly insured patients (capitation) and privately insured patients (fee-for-service) were replaced by a combined system of capitation and fee-for-service for all in 2006. The effects of these changes on the quality of care in terms of guideline adherence were investigated.

DESIGN AND SETTING

A longitudinal study from 2002 to 2009 using data from patient electronic medical records in general practice. A multilevel (patient and practice) approach was applied to study the effect of changes in the remuneration system on guideline adherence.

SUBJECTS

21 421 to 39 828 patients from 32 to 52 general practices (dynamic panel of GPs).

MAIN OUTCOME MEASURES

Sixteen guideline adherence indicators on prescriptions and referrals for acute and chronic conditions.

RESULTS

Guideline adherence increased between 2002 and 2008 by 7% for (formerly) publicly insured patients and 10% for (formerly) privately insured patients. In general, no significant differences in the trends for guideline adherence were found between privately and publicly insured patients, indicating the absence of an effect of the remuneration system on guideline adherence. Adherence to guidelines involving more time investment in terms of follow-up contacts was affected by changes in the remuneration system. For publicly insured patients, GPs showed a higher trend for guideline adherence for guidelines involving more time investment in terms of follow-up contacts compared with privately insured patients.

CONCLUSION

The change in the remuneration system had a limited impact on guideline adherence.

Public Hospital Care

In low- and middle-income countries, government budgets are rarely sufficient to cover a public hospital’s operating costs. Shortfalls are typically financed through a combination of health insurance contributions and user charges. The mixed nature of this financing arrangement potentially creates financial incentives to treat patients with equal health need unequally. Using data from the Philippines, the authors analyzed whether doctors respond to such incentives. After controlling for a patient’s condition, they found that patients using insurance, paying more for hospital accommodation, and being treated in externally monitored hospitals were likely to receive more care. This highlights the worrying possibility that public hospital patients with equal health needs are not always equally treated.

Type II diabetes patients in primary care: profiles of healthcare utilization obtained from observational data

BACKGROUND

The high burden of diabetes for healthcare costs and their impact on quality of life and management of the disease have triggered the design and introduction of disease management programmes (DMPs) in many countries. The extent to which diabetes patients vary with regard to their healthcare utilisation and costs is largely unknown and could impact on the design of DMPs. The objectives of this study are to develop profiles based on both the diabetes-related healthcare utilisation and total healthcare utilisation in primary care, to investigate which patient and disease characteristics determine 'membership' of each profile, and to investigate the association between these profiles.

METHODS

Data were used from electronic medical records of 6721 known type II diabetes patients listed in 48 Dutch general practices. Latent Class Analyses were conducted to identify profiles of healthcare and regression analyses were used to analyse the characteristics of the profiles.

RESULTS

For both diabetes-related healthcare utilisation and total healthcare utilisation three profiles could be distinguished: for the diabetes-related healthcare utilisation these were characterised as 'high utilisation and frequent home visits' (n=393), 'low utilisation, GP only' (n=3231) and 'high utilisation, GP and nurse' (n=3097). Profiles differed with respect to the patients' age and type of medication; the oldest patients using insulin were dominant in the 'high utilisation, GP and nurse' profile. High total healthcare utilisation was not associated with high diabetes-related healthcare utilisation.

CONCLUSIONS

Healthcare utilisation of diabetes patients is heterogeneous. This challenges the development of distinguishable DMPs.

Factors impacting career satisfaction of hospitalists

A study was undertaken to examine various factors that impact career satisfaction of hospitality. This study used data collected by the Center for Studying Health System Change's 2008 Health Tracking Physician survey. The 2008 HTP data set consisted of 4720 physicians belonging to the American Medical Association, of which 206 identified themselves as hospitalists. Results suggested that 41% of hospitalists were very satisfied with their careers in medicine. More than 26% of the hospitalists were 53 years or older. Seven of 10 hospitalists were men, whereas more than 55% were white. In addition, an average respondent earned between $150 000 and $200 000. Nearly 36% of the hospitalists in the study specialized in internal medicine. Regression analysis indicates that high-quality care had a highly significant impact on career satisfaction of hospitalists (P ≤ .00). In addition, formal written guidelines (P ≤ .07), gender (P ≤ .06), and white race (P ≤ .07) also had a significant impact on career satisfaction of hospitalists. It was concluded that perceived quality of care, presence of formal written guidelines, gender, and race were major predictors of career satisfaction of hospitalists.

Caries treatment in a dental practice-based research network: movement toward stated evidence-based treatment

OBJECTIVES

Practice-based research networks (PBRNs) provide a venue to foster evidence-based care. We tested the hypothesis that a higher level of participation in a dental PBRN is associated with greater stated change toward evidence-based practice.

METHODS

A total of 565 dental PBRN practitioner-investigators completed a baseline questionnaire entitled 'Assessment of Caries Diagnosis and Treatment'; 405 of these also completed a follow-up questionnaire about treatment of caries and existing restorations. Certain questions (six treatment scenarios) were repeated at follow-up a mean (SD) of 36.0 (3.8) months later. A total of 224 were 'full participants' (enrolled in clinical studies and attended at least one network meeting); 181 were 'partial participants' (did not meet 'full' criteria).

RESULTS

From 10% to 62% of practitioners were 'surgically invasive' at baseline, depending on the clinical scenario. Stated treatment approach was significantly less invasive at follow-up for four of six items. Change was greater among full participants and those with a more-invasive approach at baseline, with an overall pattern of movement away from the extremes.

CONCLUSIONS

These results are consistent with a preliminary conclusion that network participation fostered movement of scientific evidence into routine practice. PBRNs may foster movement of evidence into everyday practice as practitioners become engaged in the scientific process.

Universal health coverage and litigation in Latin America

PURPOSE

Over the last five years many middle-income Latin American countries have seen a steep increase in the number of cases litigating access to curative services. The purpose of this paper is to explore this complex phenomenon and outline some of its roots and impacts.

DESIGN/METHODOLOGY/APPROACH

The authors use an interdisciplinary approach based on a literature review and workshops convened to discuss the issue.

FINDINGS

A range of reasons can explain this increased legal activity. These include: a renewed judicial approach to the enforcement of the right to health; a more demanding public interest; an increased prevalence of non communicable diseases; and limited capacity for fair benefit package.

ORIGINALITY/VALUE

The findings in this paper argue for the need to incorporate a rights-based approach to health policy as a foundation of societal efforts to achieve universal health coverage in Latin America.

Performance scores in general practice: a comparison between the clinical versus medication-based approach to identify target populations

Context

From one country to another, the pay-for-performance mechanisms differ on one significant point: the identification of target populations, that is, populations which serve as a basis for calculating the indicators. The aim of this study was to compare clinical versus medication-based identification of populations of patients with diabetes and hypertension over the age of 50 (for men) or 60 (for women), and any consequences this may have on the calculation of P4P indicators.

Methods

A comparative, retrospective, observational study was carried out with clinical and prescription data from a panel of general practitioners (GPs), the Observatory of General Medicine (OMG) for the year 2007. Two indicators regarding the prescription for statins and aspirin in these populations were calculated.

Results

We analyzed data from 21.690 patients collected by 61 GPs via electronic medical files. Following the clinical-based approach, 2.278 patients were diabetic, 8,271 had hypertension and 1.539 had both against respectively 1.730, 8.511 and 1.304 following the medication-based approach (% agreement = 96%, kappa = 0.69). The main reasons for these differences were: forgetting to code the morbidities in the clinical approach, not taking into account the population of patients who were given life style and diet rules only or taking into account patients for whom morbidities other than hypertension could justify the use of antihypertensive drugs in the medication-based approach. The mean (confidence interval) per doctor was 33.7% (31.5–35.9) for statin indicator and 38.4% (35.4–41.4) for aspirin indicator when the target populations were identified on the basis of clinical criteria whereas they were 37.9% (36.3–39.4) and 43.8% (41.4–46.3) on the basis of treatment criteria.

Conclusion

The two approaches yield very “similar” scores but these scores cover different realities and offer food for thought on the possible usage of these indicators in the framework of P4P programmes.

Decision-making in general practice: the effect of financial incentives on the use of laboratory analyses

This paper examines the reaction of general practitioners (GPs) to a reform in 2004 in the remuneration system for using laboratory services in general practice. The purpose of this paper is to study whether income motivation exists regarding the use of laboratory services in general practice, and if so, the degree of income motivation among general practitioners (GPs) in Norway. We argue that the degree of income motivation is stronger when the physicians are uncertain about the utility of the laboratory service in question. We have panel data from actual physician-patient encounters in general practices in the years 2001-2004 and use discrete choice analysis and random effects models. Estimation results show that an increase in the fees will lead to a small but significant increase in use. The reform led to minor changes in the use of laboratory analyses in GPs' offices, and we argue that financial incentives were diluted because they were in conflict with medical recommendations and existing medical practice. The patient's age has the most influence and the results support the hypothesis that the impact of income increases with increasing uncertainty about diagnosis and treatment. The policy implication of our results is that financial incentives alone are not an effective tool for influencing the use of laboratory services in GPs' offices.

Patient-care time allocation by nurse practitioners and physician assistants in the intensive care unit

Introduction

Use of nurse practitioners and physician assistants ("affiliates") is increasing significantly in the intensive care unit (ICU). Despite this, few data exist on how affiliates allocate their time in the ICU. The purpose of this study was to understand the allocation of affiliate time into patient-care and non-patient-care activity, further dividing the time devoted to patient care into billable service and equally important but nonbillable care.

Methods

We conducted a quasi experimental study in seven ICUs in an academic hospital and a hybrid academic/community hospital. After a period of self-reporting, a one-time monetary incentive of $2,500 was offered to 39 affiliates in each ICU in which every affiliate documented greater than 75% of their time devoted to patient care over a 6-month period in an effort to understand how affiliates allocated their time throughout a shift. Documentation included billable time (critical care, evaluation and management, procedures) and a new category ("zero charge time"), which facilitated record keeping of other patient-care activities.

Results

At baseline, no ICUs had documentation of 75% patient-care time by all of its affiliates. In the 6 months in which reporting was tied to a group incentive, six of seven ICUs had every affiliate document greater than 75% of their time. Individual time documentation increased from 53% to 84%. Zero-charge time accounted for an average of 21% of each shift. The most common reason was rounding, which accounted for nearly half of all zero-charge time. Sign out, chart review, and teaching were the next most common zero-charge activities. Documentation of time spent on billable activities also increased from 53% of an affiliate's shift to 63%. Time documentation was similar regardless of during which shift an affiliate worked.

Conclusions

Approximately two thirds of an affiliate's shift is spent providing billable services to patients. Greater than 20% of each shift is spent providing equally important but not reimbursable patient care. Understanding how affiliates spend their time and what proportion of time is spent in billable activities can be used to plan the financial impact of staffing ICUs with affiliates.

Variation in HbA1c prescription for patients with diabetes in French general practice: an observational study prior to the implementation of a P4P programme

BACKGROUND

Prior to a large diffusion of a pay-for-performance programme (P4P) in primary care in France, it seemed of particular interest to identify, the doctors not performing optimally who could be the main target of this programme. Based on the example of HbA1c prescription for patients with diabetes, this study examined the impact of general practitioner's (GPs) characteristics on the variation of a P4P indicator for diabetes care, i.e. the percentage of patients undergoing three or four HbA1c tests during one year.

METHODS

We used a large database from the national health insurance fund for salaried workers in Brittany to select a cohort of patients with diabetes who had been attended to by their doctors for 1 year. In all, 2545 GPs attending to 41,453 patients with diabetes were included. A two-level hierarchical logistic model was used to analyse the data.

RESULTS

Thirty-six per cent (SD = 22.3) of patients with diabetes underwent three or four HbA1c tests during the year (the target objective was 65% in a patient list). There was a large variability between GPs, even after adjusting for patient characteristics. Doctors who were female, young, working in a group practice, participating in quality-control groups, and who had a lower patient load prescribed the three or four recommended tests more often.

DISCUSSION

The results indicate a target group of doctors which require attention. There is still room to improve the quality of care for patients with diabetes in general practice, notably by encouraging doctors to train better and practice in groups.

Effect of financial relationships on the behaviors of health care professionals: a review of the evidence

This paper explores the empirical evidence regarding the impact financial relationships on the behavior of health care providers, specifically, physicians. We identify and synthesize peer-reviewed data addressing whether financial incentives are causally related to patient outcomes and health care costs. We cover three main areas where financial conflicts of interest arise and may have an observable relationship to health care practices: (1) physicians' roles as self-referrers, (2) insurance reimbursement schemes that create incentives for certain clinical choices over others, and (3) financial relationships between physicians and the drug and device industries. We found a well-developed scientific literature consisting of dozens of empirical studies, some that allow stronger causal inferences than others, but which altogether show that such financial conflicts of interests can, and sometimes do, impact physicians' clinical decisions. Further research is warranted to document the causal relationship of such changes on health outcomes and the cost of care, but the current base of evidence is sufficiently robust to motivate policy reform.

Physician practice responses to financial incentive programs: exploring the concept of implementation mechanisms

PURPOSE

To develop a framework for studying financial incentive program implementation mechanisms, the means by which physician practices and physicians translate incentive program goals into their specific office setting. Understanding how new financial incentives fit with the structure of physician practices and individual providers' work may shed some insight on the variable effects of physician incentives documented in numerous reviews and meta-analyses.

DESIGN/METHODOLOGY/APPROACH

Reviewing select articles on pay-for-performance evaluations to identify and characterize the presence of implementation mechanisms for designing, communicating, implementing, and maintaining financial incentive programs as well as recognizing participants' success and effects on patient care.

FINDINGS

Although uncommonly included in evaluations, evidence from 26 articles reveals financial incentive program sponsors and participants utilized a variety of strategies to facilitate communication about program goals and intentions, to provide feedback about participants' progress, and to assist-practices in providing recommended services. Despite diversity in programs' geographic locations, clinical targets, scope, and market context, sponsors and participants deployed common strategies. While these methods largely pertained to communication between program sponsors and participants and the provision of information about performance through reports and registries, they also included other activities such as efforts to engage patients and ways to change staff roles.

LIMITATIONS

This review covers a limited body of research to develop a conceptual framework for future research; it did not exhaustively search for new articles and cannot definitively link particular implementation mechanisms to outcomes.

PRACTICAL IMPLICATIONS

Our results underscore the effects implementation mechanisms may have on how practices incorporate new programs into existing systems of care which implicates both the potential rewards from small changes as well as the resources which may be required to obtain buy-in and support.

ORIGINALITY/VALUE

We identify gaps in previous research regarding actual changes occurring in physician practices in response to physician incentive programs. We offer suggestions for future evaluation by proposing a framework for understanding implementation. Our model will assist future scholars in translating site-specific experiences with incentive programs into more broadly relevant guidance for practices by facilitating comparisons across seemingly disparate programs.

The effects of drug market regulation on pharmaceutical prices in Europe: overview and evidence from the market of ACE inhibitors

This study provides an overview of policy measures targeting pharmaceutical expenditure in Europe and analyses their impact on originator pharmaceutical prices. Panel data methods are used to examine the market of ACE Inhibitors in six European countries (Denmark, France, Germany, Netherlands, Sweden, United Kingdom) over period 1991-2006. We find that although some measures are effective in reducing originator prices, others appear to have an insignificant effect. Results suggest that supply side measures such as mandatory generic substitution, regressive pharmacy mark-ups and claw-backs are effective in reducing pharmaceuticals prices. Results are not as strong for demand side measures. Profit controls and the use of cost-effectiveness analysis appear to have a negative effect on prices, while results on reference pricing are inconclusive. Findings also indicate that, although originator prices are not immediately affected by generic entry, they may be influenced by changes in generic prices post patent expiry.

Pay-for-performance in disease management: a systematic review of the literature

BACKGROUND

Pay-for-performance (P4P) is increasingly implemented in the healthcare system to encourage improvements in healthcare quality. P4P is a payment model that rewards healthcare providers for meeting pre-established targets for delivery of healthcare services by financial incentives. Based on their performance, healthcare providers receive either additional or reduced payment. Currently, little is known about P4P schemes intending to improve delivery of chronic care through disease management. The objectives of this paper are therefore to provide an overview of P4P schemes used to stimulate delivery of chronic care through disease management and to provide insight into their effects on healthcare quality and costs.

METHODS

A systematic PubMed search was performed for English language papers published between 2000 and 2010 describing P4P schemes related to the implementation of disease management. Wagner's chronic care model was used to make disease management operational.

RESULTS

Eight P4P schemes were identified, introduced in the USA (n = 6), Germany (n = 1), and Australia (n = 1). Five P4P schemes were part of a larger scheme of interventions to improve quality of care, whereas three P4P schemes were solely implemented. Most financial incentives were rewards, selective, and granted on the basis of absolute performance. More variation was found in incented entities and the basis for providing incentives. Information about motivation, certainty, size, frequency, and duration of the financial incentives was generally limited. Five studies were identified that evaluated the effects of P4P on healthcare quality. Most studies showed positive effects of P4P on healthcare quality. No studies were found that evaluated the effects of P4P on healthcare costs.

CONCLUSION

The number of P4P schemes to encourage disease management is limited. Hardly any information is available about the effects of such schemes on healthcare quality and costs.

Pay-for-virtue: an option to improve pay-for-performance?

Pay-for-performance schemes reward standardized professional behaviours associated with effective care. However, they neglect the significance of virtue and devalue and erode professional motivation based on virtue. Pay for training to cultivate virtue, and/or pay-for-virtue, may mitigate these dangers. Although virtue is typically considered its own reward, and the assessment of virtue is problematic, pay-for-virtue could involve (1) stringent checks on the appropriateness of the standardized care currently rewarded by pay-for-performance for individual patients or (2) pay for indicators of virtue. These indicators could be based on virtues identified from a framework of universal virtues and through logical inferences from features of practice. It is possible that pay-for-virtue could ultimately strengthen health professionals' intrinsic motivation for good practice, but this and the broader effects of pay-for-virtue would need careful investigation.