Quality-based purchasing in health care

Realigning the provider payment system for primary health care: a pilot study in a rural county of Zhejiang Province, China

Aim:

This work aimed to evaluate a pre/post-reform pilot study from 2015 to 2018 in a rural county of Zhejiang Province, China to realign the provider payment system for primary health care (PHC).

Methods:

Data were extracted from the National Health Financial Annual Reports for the 21 township health centers (THCs) in Shengzhou County. An information system was designed for the reform. Differences among independent groups were assessed using Kruskal–Wallis H-test. Dunn’s post hoc test was used for multiple comparisons. Differences between paired groups were tested by Wilcoxon signed-rank test. Two-tailed P < 0.05 indicated statistical significance. Data were processed and analyzed using R 3.6.1 for Windows.

Findings:

First, payments to THCs shifted from a “soft budget” to a mixed system of line-item input-based and categorized output-based payments, accounting for 17.54% and 82.46%, respectively, of total revenue in 2017. Second, providers were more motivated to deliver services after the reform; total volumes increased by 27.80%, 19.22%, and 30.31% for inpatient visits, outpatient visits, and the National Essential Public Health Services Package (NEPHSP), respectively. Third, NEPHSP payments were shifted from capitation to resource-based relative value scale (RBRVS) payments, resulting in a change in the NEPHSP subsidy from 36.41 to 67.35 per capita among the 21 THCs in 2017. Fourth, incentive merit pay to primary health physicians accounted for 38.40% of total salary, and the average salary increased by 32.74%, with a 32.45% increase in working intensity. A small proportion of penalties for unqualified products and pay-for-performance rewards were blended with the payments. The reform should be modified to motivate providers in remote areas.

Conclusion:

In the context of a profit-driven, hospital-centered system, add-on payments – including categorized output-based payments to THCs and incentive merit pay to primary care physicians (PCPs) – are probably worth pursuing to achieve more active and output/outcome-based PHC in China.

Cumulative Prospect Theory: Performance Evaluation of Government Purchases of Home-Based Elderly-Care Services Using the Pythagorean 2-tuple Linguistic TODIM Method

The aging trend of China's population is increasing, and the pension problem is becoming increasingly prominent. The pension mode provided by the government alone can no longer meet the social demand, and the government's purchase of home-based care services from social organizations has become a new trend. In order to improve the efficiency and quality of pension services, a reasonable performance evaluation model needs to be established. Performance evaluations of home-based elderly-care services purchased by the government are problematic as a result of multiple-attribute group decision-making (MAGDM), as the problems are not single-attribute or single-expert issues. The extended TODIM not only integrates the advantages of cumulative prospect theory (CPT) into a consideration of the psychological factors of DMs, but also retains the superiority of the classical TODIM in relative dominance. The Pythagorean 2-tuple linguistic sets (P2TLSs) could easily depict qualitative assessment information related to the government's purchase of home-based care services. Thus, in this paper, we extend the TODIM method based on the cumulative prospect theory (CPT) to the Pythagorean 2-tuple linguistic sets (P2TLSs) and propose a Pythagorean 2-tuple linguistic CPT-TODIM (P2TL-CPT-TODIM) method for MAGDM. The P2TL-CPT-TODIM method was proven superior to the classical one through a case study that included a performance evaluation of a home-based elderly-care service purchased by the government. Meanwhile, a comparison with the P2TL-CPT-TODIM method was performed to demonstrate the stability and effectiveness of the designed method.

Provider payment to primary care physicians in China: background, challenges, and a reform framework

Aim: To provide a framework for provider payment reform for primary care physicians in China. Background: Primary health care is central to health system reform and payment incentives have significant consequences for the equity and efficiency of it. Methods: This paper describes the special payments system for public primary health institutions and the subsequent internal salary remuneration to primary care physicians in China. Based on an analysis of the major challenges, we suggest a reform framework including the pattern of governance, and payments to primary health institutions and employed physicians. Findings: A mixed system of input-based and output-based payments to institutions would probably be appropriate under a long-term and relational contract with the government. It was also advised that internal remuneration is provided by a basic salary plus a bonus based on performance, and an extra-regional allowance. We hope that the results can be used to shift the passive budgeting of in-house staff within the public primary health institutions toward strategic purchasing.

Do beneficiaries' views matter in healthcare purchasing decisions? Experiences from the Nigerian tax-funded health system and the formal sector social health insurance program of the National Health Insurance Scheme

Background

Purchasing is a health financing function that involves the transfer of pooled resources to providers on behalf of a covered population. Little attention has been paid to the extent to which the views of that population  are reflected in purchasing decisions. This article explores how purchasers in two financing mechanisms: the Formal Sector Social Health Insurance Programme (FSSHIP) operating under the Nigerian National Health Insurance Scheme (NHIS), and the tax-funded health system perform their roles in light of their responsibilities to the populations.

Methods

A case study approach was adopted in which each financing mechanism is a case. Sixteen (16) in-depth interviews with purchasers and eight (8) focus group discussions with beneficiaries were held. Agency and organizational behavioural theories were used to characterise the purchaser-citizen relationships. A deductive framework approach was used to assess whether actions identified in a model of ‘ideal’ strategic purchasing actions were undertaken in each case.

Results

For both cases, mechanisms exist to reflect people’s health needs in purchasing decisions, including quantitative and qualitative needs assessment, mechanisms to raise awareness of benefit entitlements and allow choice. However, purchasers do not use the mechanisms to effectively engage with and hold themselves accountable to the people. In the tax-funded system, weak information systems and unclear communication channels between the purchaser and citizens constrain assessment of needs; while timeliness of health information and poor engagement practices of Health Maintenance Organisations (HMOs) are the main constraints in FSSHIP. Inadequate information sharing in both mechanisms limits beneficiaries’ awareness of entitlements. Although beneficiaries of FSSHIP can choose providers, lack of information on the quality of services offered by providers constrains rational decision-making and the inability to change HMOs reduces HMO responsiveness to beneficiary needs.

Conclusions

Responsiveness and accountability to beneficiaries are undervalued by purchasers in both financing mechanisms. In the tax-funded system, civil society organisations can facilitate engagement and accountability of purchasers and the people. In FSSHIP, NHIS needs to provide stronger stewardship of HMOs to promote effective engagement with members. Furthermore, the NHIS should introduce mechanisms that allow FSSHIP members to choose their own HMO, which could encourage HMOs to be more responsive to members.

Performance-based contracting in home-care work in The Netherlands: professionalism under pressure?

Our aim was to improve the understanding of the relationships between performance-based contracting, management supportiveness and professionalism in home care. Using path analysis, this article explores the relationships between home-care workers' perceptions of management support, implementation of performance-based contracting (i.e. use of strict time registration rules and cost-efficiency measures) and autonomy and intrinsic job satisfaction. We hypothesised that: use of strict time registration rules and cost-efficiency measures relates to lower levels of autonomy and intrinsic job satisfaction (H1); there is an indirect relationship between use of strict time registration rules and use of cost-efficiency measures and intrinsic job satisfaction via autonomy (H2); higher levels of management support relate to the use of looser time registration rules and less use of cost-efficiency measures (H3); and higher levels of management support relate to higher levels of autonomy and intrinsic job satisfaction (H4). We used data from a cross-sectional survey conducted in 2010 of a sample of Dutch home-care workers (N = 156, response rate = 34%). Overall, our study suggests that the consequences of performance-based contracting for professionalism are ambiguous. More specifically, using strict time registration rules is related to lower levels of autonomy, whereas using cost-efficiency measures does not seem to affect autonomy (H1). Performance-based contracting has no consequences for the level of fulfilment home-care workers find in their job, as neither of the two contracting dimensions measured was directly or indirectly related to intrinsic job satisfaction (H1, H2). The role of managers must be taken into account when studying performance-based contracting, because perceived higher management support is related to managers' less frequent use of both strict time registration rules and of cost-efficiency measures (H3). The insight we gained into the importance of supportive managers for both autonomy and job satisfaction (H4) can help home-care organisations improve the attractiveness of home-care work.

Quality and legal aspects in public care procurement

Purpose

– The purpose of this paper is to assess the applicability of care quality concepts as contract award criteria for public procurement of health and social care, using the case of Sweden.

Design/methodology/approach

– Based on a literature review, European and Swedish legal texts, government regulations as well as 26 Swedish court review cases concerning care procurement have been analysed.

Findings

– Methods used for assessing care quality are seldom useful for predicting the quality to be delivered by a potential contractor. Legal principles of transparency and equal treatment of tenderers make it necessary to apply strict requirements for verification.

Research limitations/implications

– Results refer primarily to a Swedish context but could be applicable throughout the EU. Further studies of relations between award criteria and public/private collaborative practices for improving care quality during contractual periods are desirable.

Practical implications

– Local and regional procurement officials should benefit from a better understanding of how quality criteria should be designed and applied to the award procedures for care contracts. Care providers in the private sector would also be able to develop their quality strategies and present their abilities more efficiently when tendering for public contracts.

Social implications

– Issues of quality of health and social care are of obvious importance for social sustainability. Public awareness of care quality problems is evident and often a cause of media concern.

Originality/value

– This investigation pinpoints the difference between traditional care quality thinking and the legal principles underlying contract award in public procurement of care services.

Collaborative purchasing of complex technologies in healthcare

Purpose

– The purpose of this paper is to investigate how buyers and the vendors pursue alignment in collaborative purchasing (CP) of complex medical technologies.

Design/methodology/approach

– Through a literature review in CP, the paper identify factors for shareholder alignment (i.e. aligning the needs of the buyers within the purchasing group) and customer alignment (i.e. aligning buyers’ needs with the vendors offering strategies) and investigate how they manifest in the case of CP of complex technology in the Danish National Healthcare System.

Findings

– Shareholder alignment requires appropriate management of the relationships, expertise and guidance in simplifying procedures and effective management of the purchasing group. Customer alignment is facilitated by buyers’ understating of the vendor’s design options, which are moderated by the vendor’s design strategies.

Research limitations/implications

– The findings and generalizations from a single case study are limited to the complexity of the purchased technology and the specific cultural context. However the paper represents the first explorative study that poses the attention on the relevance of shareholder and customer alignment in CP.

Practical implications

– The study can offer hospitals, vendors, governmental and regional institutions a better understanding about the alignment mechanisms for successful implementation of CP and how to avoid pitfalls.

Originality/value

– Literature on CP is scarce as there are virtually no contributions that debate the key elements and tradeoffs that need to be considered for strategic alignment. The study addresses this gap.

Estrutura e qualidade assistencial dos prestadores de serviços hospitalares à saúde suplementar no Brasil

Este trabalho objetivou caracterizar os prestadores de serviços hospitalares no setor de saúde suplementar, uma vez que o conhecimento sobre tais prestadores ainda é incipiente, particularmente em relação à estrutura e à qualidade assistencial. Foi realizado um inquérito nacional, tendo como universo de interesse 3.817 hospitais. Uma amostra estratificada de 83 hospitais foi selecionada. A coleta de dados ocorreu entre setembro e dezembro de 2006, por meio de entrevistas com os dirigentes dos hospitais. Para a caracterização assistencial dos hospitais, foram contempladas variáveis relativas à capacidade instalada e produção de serviços, bem como às práticas e estruturas de garantia e monitoramento da qualidade do cuidado. A amostra final pesquisada resultou em 74 hospitais, correspondendo a um universo estimado de 3.799 unidades. Os hospitais prestadores de serviços para operadoras, majoritariamente provedores de serviços ao Sistema Único de Saúde (SUS), apresentaram baixa presença de estruturas e práticas de qualificação da gestão e de monitoramento da qualidade assistencial.

Pay for performance in orthopaedic surgery

In recent decades American medicine has undergone tremendous changes. Numerous reimbursement and systems approaches to controlling medical inflation and improving quality have failed to provide cost-effective, high-quality health care in most circumstances. Public and private payers are currently implementing pay for performance, a new reimbursement method linking physician pay to evidence of adherence to performance measures, to constrain costs, encourage efficiency, and maximize value for health care dollars. High-quality research regarding pay for performance and its impact is scarce, particularly in orthopaedic surgery. Although supporters argue pay for performance will remedy the fragmented, costly delivery of health services in the United States, skeptics raise concerns about disagreement over quality guidelines, financial implications for providers and hospitals, inadequate infrastructure, public reporting, system gaming, and physician support. Our survey of orthopaedic surgeons reveals limited understanding of pay for performance, marked skepticism of nonphysician stakeholders' intentions, and a strong desire for greater clinician involvement in shaping the pay for performance movement. As pay for performance will likely be a long-term change that will have an impact on every orthopaedic surgeon, clinician awareness and participation will be fundamental in creating successful pay for performance programs.