Key issues in the design of pay for performance programs

Understanding the municipal-level design and adaptation of pay-for-performance schemes across two states of Brazil

The design of complex health systems interventions, such as pay for performance (P4P), can be critical to determining such programmes' success. In P4P programmes, the design of financial incentives is crucial in shaping how these programmes work. However, the design of such schemes is usually homogenous across providers within a given scheme. Consequently, there is a limited understanding of the strengths and weaknesses of P4P design elements from the implementers' perspective. This study takes advantage of the unique context of Brazil, where municipalities adapted the federal incentive design, resulting in variations in incentive design across municipalities. The study aims to understand why municipalities in Brazil chose certain P4P design features, the associated challenges and the local adaptations made to address problems in scheme design. This study was a multiple case study design relying on qualitative data from 20 municipalities from two states in Northeastern Brazil. We conducted two key informant interviews with municipal-level stakeholders and focus group discussions with primary care providers. We also reviewed municipal Primary Care Access and Quality laws in each municipality. We found substantial variation in the design choices made by municipalities regarding 'who was incentivized', the 'payment size' and 'frequency'. Design choices affected relationships within municipalities and within teams. Challenges were chiefly associated with fairness relating to 'who received the incentive', 'what is incentivized' and the 'incentive size'. Adaptations were made to improve fairness, mostly in response to pressure from the healthcare workers. The significant variation in design choices across municipalities and providers' response to them highlights the importance of considering local context in the design and implementation of P4P schemes and ensuring flexibility to accommodate local preferences and emerging needs. Attention is needed to ensure that the choice of 'who is incentivized' and the 'size of incentives' are inclusive and fair and the allocation and 'use of funds' are transparent.

Pay-for-Performance incentives for specialised services in England: a mixed methods evaluation

BACKGROUND

A Pay-for-Performance (P4P) programme, known as Prescribed Specialised Services Commissioning for Quality and Innovation (PSS CQUIN), was introduced for specialised services in the English NHS in 2013/2014. These services treat patients with rare and complex conditions. We evaluate the implementation of PSS CQUIN contracts between 2016/2017 and 2018/2019.

METHODS

We used a mixed methods evaluative approach. In the quantitative analysis, we used a difference-in-differences design to evaluate the effectiveness of ten PSS CQUIN schemes across a range of targeted outcomes. Potential selection bias was addressed using propensity score matching. We also estimated impacts on costs by scheme and financial year. In the qualitative analysis, we conducted semi-structured interviews and focus group discussions to gain insights into the complexities of contract design and programme implementation. Qualitative data analysis was based on the constant comparative method, inductively generating themes.

RESULTS

The ten PSS CQUIN schemes had limited impact on the targeted outcomes. A statistically significant improvement was found for only one scheme: in the clinical area of trauma, the incentive scheme increased the probability of being discharged from Adult Critical Care within four hours of being clinically ready by 7%. The limited impact may be due to the size of the incentive payments, the complexity of the schemes' design, and issues around ownership, contracting and flexibility.

CONCLUSION

The PSS CQUIN schemes had little or no impact on quality improvements in specialised services. Future P4P programmes in healthcare could benefit from lessons learnt from this study on incentive design and programme implementation.

Does pay-for-performance design matter? Evidence from Brazil

Pay-for-performance (P4P) schemes have been shown to have mixed effects on health care outcomes. A challenge in interpreting this evidence is that P4P is often considered a homogenous intervention, when in practice schemes vary widely in their design. Our study contributes to this literature by providing a detailed depiction of incentive design across municipalities within a national P4P scheme in Brazil [Primary Care Access and Quality (PMAQ)] and exploring the association of alternative design typologies with the performance of primary health care providers. We carried out a nation-wide survey of municipal health managers to characterize the scheme design, based on the size of the bonus, the providers incentivized and the frequency of payment. Using OLS regressions and controlling for municipality characteristics, we examined whether each design feature was associated with better family health team (FHT) performance. To capture potential interactions between design features, we used cluster analysis to group municipalities into five design typologies and then examined associations with quality of care. A majority of the municipalities included in our study used some of the PMAQ funds to provide bonuses to FHT workers, while the remaining municipalities spent the funds in the traditional way using input-based budgets. Frequent bonus payments (monthly) and higher size bonus allocations (share of 20-80%) were strongly associated with better team performance, while who within a team was eligible to receive bonuses did not in isolation appear to influence performance. The cluster analysis showed what combinations of design features were associated with better performance. The PMAQ score in the 'large bonus/many workers/high-frequency' cluster was 8.44 points higher than the 'no bonus' cluster, equivalent to a difference of 21.7% in the mean PMAQ score. Evidence from our study shows how design features can potentially influence health provider performance, informing the design of more effective P4P schemes.

Inciting maintenance: Tiered institutional work during value-based payment reform in oncology

Value-based payment aims to shift the focus from traditional volume-driven arrangements to a system that rewards providers for the quality and value of care delivered. Previous research has shown that it is difficult for providers to change their medical and organizational practices to adopt value-based payment, but the role of actors in these reforms has remained underexposed. This paper unravels the motives of non-clinical and clinical professionals to maintain institutionalized payment practices when faced with value-based payment. To illuminate these motives, a case study was conducted in a Dutch hospital alliance that aimed to implement value-based payment to incentivize the transition to novel interventions in a prostate cancer care pathway. Data collection consisted of observations and interviews with actors on multiple levels in the hospital (sales departments, medical specialist enterprises (MSEs) and physicians). On each actor level, motives for maintaining currently prevailing institutional practices were present. Regulative maintenance motives were more common for sales managers whereas cultural-cognitive and normative motives seemed to play an important role for physicians. An overarching motive was that desired transitions to novel interventions proved possible under the currently prevailing institutional logic, dismissing an urgent need for payment reform. Our analysis further revealed that actors engage in diverse institutional maintenance work, and that some actor groups' institutional work carries more weight than others because of the dependency relationships that exist between hospitals, MSEs and physicians. Physicians depend on MSEs and sales departments, who act as gatekeepers and buffers, to decide whether the value-based payment reform is either adopted or abandoned.

Primary care providers' preferences for pay-for-performance programs: a discrete choice experiment study in Shandong China

BACKGROUND

Pay-for-performance (P4P) schemes are commonly used to incentivize primary healthcare (PHC) providers to improve the quality of care they deliver. However, the effectiveness of P4P schemes can vary depending on their design. In this study, we aimed to investigate the preferences of PHC providers for participating in P4P programs in a city in Shandong province, China.

METHOD

We conducted a discrete choice experiment (DCE) with 882 PHC providers, using six attributes: type of incentive, whom to incentivize, frequency of incentive, size of incentive, the domain of performance measurement, and release of performance results. Mixed logit models and latent class models were used for the statistical analyses.

RESULTS

Our results showed that PHC providers had a strong negative preference for fines compared to bonuses (- 1.91; 95%CI - 2.13 to - 1.69) and for annual incentive payments compared to monthly (- 1.37; 95%CI - 1.59 to - 1.14). Providers also showed negative preferences for incentive size of 60% of monthly income, group incentives, and non-release of performance results. On the other hand, an incentive size of 20% of monthly income and including quality of care in performance measures were preferred. We identified four distinct classes of providers with different preferences for P4P schemes. Class 2 and Class 3 valued most of the attributes differently, while Class 1 and Class 4 had a relatively small influence from most attributes.

CONCLUSION

P4P schemes that offer bonuses rather than fines, monthly rather than annual payments, incentive size of 20% of monthly income, paid to individuals, including quality of care in performance measures, and release of performance results are likely to be more effective in improving PHC performance. Our findings also highlight the importance of considering preference heterogeneity when designing P4P schemes.

A roadmap for sustainable implementation of vocational rehabilitation for people with mental disorders and its outcomes: a qualitative evaluation

BACKGROUND

People suffering from mental health disorders have lower work participation compared to people without mental challenges. To increase work participation within this group vocational rehabilitation interventions are often offered. Collaboration between the mental health care and social security sectors is needed to enable professionals to perform optimally when carrying out these interventions. Yet, regulatory and financial barriers often hinder sustainable implementation. To overcome these barriers an experimental roadmap for sustainable funding based on a shared savings strategy was piloted in four regions. The aim of the present qualitative study was to gain understanding of the uses of this roadmap and the factors that were important in the experiment's process.

METHOD

The roadmap consisted of five steps based upon insights from shared savings strategies and implementation science knowledge, and was initiated by a national steering board. The roadmap aimed to make sustainable funding agreements (based on shared savings) for the implementation of a vocational rehabilitation intervention. In four regions, stakeholders from the mental health care and social security services sector followed the roadmap. We conducted interviews (n = 16) with involved participants and project leaders of the experiment and collected 54 sets of field notes and documents to evaluate the roadmap process. A thematic analysis was used to analyse the data.

RESULTS

Regions perceived improved stakeholder collaboration around vocational rehabilitation after they were guided by the roadmap. Three regions made, or intended to make, agreements on collaboration and funding, yet not based on shared savings. Moreover, going through the roadmap took more time than anticipated. Stakeholder collaboration depended on factors like personal and organizational interests and collaboration conditions and values. Financial legislation and politics were regarded as barriers and personal motives were mentioned as a facilitator in this process.

CONCLUSIONS

Our study showed that the roadmap supported stakeholders to establish a more sustainable collaboration, even though no sustainable financial agreements were made yet. Although participants acknowledged the function of financial insights and the need for financial resources, the driver for collaboration was found to be more on improving clients' perspectives than on solving unfair financial distribution issues. This suggests modifying the focus of the roadmap from financial benefits to improving clients' perspectives.

Facilitating and Inhibiting Factors in the Design, Implementation, and Applicability of Value-Based Payment Models: A Systematic Literature Review

Evidence on the potential for value-based payment models to improve quality of care and ensure more efficient outcomes is limited and mixed. We aim to identify the factors that enhance or inhibit the design, implementation, and application of these models through a systematic literature review. We used the PRISMA guidelines. The facilitating and inhibiting factors were divided into subcategories according to a theoretical framework. We included 143 publications, each reporting multiple factors. Facilitators on objectives and strategies, such as realistic/achievable targets, are reported in 56 studies. Barriers regarding dedicated time and resources (e.g., an excessive amount of time for improvements to manifest) are reported in 25 studies. Consensus within the network regarding objectives and strategies, trust, and good coordination is essential. Health care staff needs to be kept motivated, well-informed, and actively involved. In addition, stakeholders should manage expectations regarding when results are expected to be achieved.

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.

Incorporating Safety and Quality Measures Into Australia's Activity-Based Funding of Public Hospital Services

In a bid to improve quality of care, numerous countries have incorporated rewards and penalties into the funding and pricing of hospital services. This paper outlines recent advances in Australia to incorporate financial penalties for hospital acquired complications (HACs) and avoidable hospital readmissions (AHRs) adjustments into the funding of public hospital services. It describes the work in the development of suitable measures to identify episodes, the design of the analytical approach used for risk adjustment and the calculation of the funding implications including dampening effects to account for the level of risk. Using the 2019 to 20 round of data collection, this paper reports on the risk adjustment analysis, incremental costs of HACs and AHRs, and the funding dampening effects, the paper further discusses the implementation strategies undertaken by the Independent Health and Aged Care Pricing Authority (IHACPA) to ensure transparency, stakeholder consultation and engagement. The paper argues that both the technical development and its implementation strategies have been central to making safety and quality an integral and accepted part of Australia's public hospital funding arrangements.

Assessing Taiwan's pay-for-performance program for diabetes care: a cost-benefit net value approach

Pay-for-Performance (P4P) to better manage chronic conditions has yielded mixed results. A better understanding of the cost and benefit of P4P is needed to improve program assessment. To this end, we assessed the effect of a P4P program using a quasi-experimental intervention and control design. Two different intervention groups were used, one consisting of newly enrolled P4P patients, and another using P4P patients who have been enrolled since the beginning of the study. Patient-level data on clinical indicators, utilization and expenditures, linked with national death registry, were collected for diabetic patients at a large regional hospital in Taiwan between 2007 and 2013. Net value, defined as the value of life years gained minus the cost of care, is calculated and compared for the intervention group of P4P patients with propensity score-matched non-P4P samples. We found that Taiwan's implementation of the P4P program for diabetic care yielded positive net values, ranging from $40,084 USD to $348,717 USD, with higher net values in the continuous enrollment model. Our results suggest that the health benefits from P4P enrollment may require a sufficient time frame to manifest, so a net value approach incorporating future predicted mortality risks may be especially important for studying chronic disease management. Future research on the mechanisms by which the Taiwan P4P program helped improve outcomes could help translate our findings to other clinical contexts.

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.

Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single-payer health system

BACKGROUND

Enrollment in and adherence to a diabetes pay-for-performance (P4P) program can lead to desirable processes and outcomes of diabetes care. However, knowledge is limited on the potential exclusion of patients with individual or neighborhood social risks or interruption of services in the disease-specific P4P program without mandatory participation under a single-payer health system.

OBJECTIVE

To investigate the impact of individual and neighborhood social risks on exclusion from and adherence to the diabetes P4P program of patients with type 2 diabetes (T2D) in Taiwan.

METHODS

This study used data from Taiwan's 2009-2017 population-based National Health Insurance Research Database, 2010 Population and Housing Census, and 2010 Income Tax Statistics. A retrospective cohort study was conducted, and study populations were identified from 2012 to 2014. The first cohort comprised 183,806 patients with newly diagnosed T2D, who had undergone follow up for 1 year; the second cohort consisted of 78,602 P4P patients who had undergone follow up for 2 years after P4P enrollment. Binary logistic regression models were used to examine the associations of social risks with exclusion from and adherence to the diabetes P4P program.

RESULTS

T2D patients with higher individual social risks were more likely to be excluded from the P4P program, but those with higher neighborhood-level social risks were slightly less likely to be excluded. T2D patients with the higher individual- or neighborhood-level social risks showed less likelihood of adhering to the program, and the person-level coefficient was stronger in magnitude than the neighborhood-level one.

CONCLUSIONS

Our results indicate the importance of individual social risk adjustment and special financial incentives in disease-specific P4P programs. Strategies for improving program adherence should consider individual and neighborhood social risks.

Alignment in the Hospital-Physician Relationship: A Qualitative Multiple Case Study of Medical Specialist Enterprises in the Netherlands

BACKGROUND

Policy-makers and hospital boards throughout the world have implemented different measures to create and sustain effective hospital-physician relationships. The 'integrated funding' policy reform in the Netherlands was aimed at increasing hospital-physician alignment and led to the unforeseen formation of medical specialist enterprises (MSEs): a fiscal entity representing all self-employed physicians in a hospital. It is unknown how hospitals and MSEs perceive their alignment and how they govern the relationship. This study explores the hospital-MSE relationship, and how governance styles influence perceived alignment in this relationship.

METHODS

A multiple case study of five non-academic hospitals in the Netherlands was performed. Data was derived from two sources: (1) analysis of hospital-MSE contracts and (2) semi-structured interviews with hospital and MSE board members. Contracts were analysed using a predefined contract analysis template. Interview recordings were transcribed and subsequently coded using the sensitizing concepts approach.

RESULTS

Contracts, relational characteristics, governance styles and perceived alignment differed substantially between cases. Two out of five contracts were prevention contracts, one was a mixed type, and two were promotion contracts. However, in all cases the contract played no role in the relationship. The use of incentives varied widely between the hospitals; most incentives were financial penalties. The governance style varied between contractual for two hospitals, mixed for one hospital and predominantly relational for two hospitals. Development of a shared business strategy was identified as an important driver of relational governance, which was perceived to boost alignment.

CONCLUSION

Large variation was observed regarding relational characteristics, governance and perceived alignment. MSE formation was perceived to have contributed to hospital-physician alignment by uniting physicians, boosting physicians' managerial responsibilities, increasing financial alignment and developing shared business strategies. Relational governance was found to promote intensive collaboration between hospital and MSE, and thus may improve alignment in the hospital-physician relationship.

Performance bonuses and the quality of primary health care delivered by family health teams in Brazil: A difference-in-differences analysis

BACKGROUND

Pay-for-performance (P4P) programmes to incentivise health providers to improve quality of care have been widely implemented globally. Despite intuitive appeal, evidence on the effectiveness of P4P is mixed, potentially due to differences in how schemes are designed. We exploited municipality variation in the design features of Brazil's National Programme for Improving Primary Care Access and Quality (PMAQ) to examine whether performance bonuses given to family health team workers were associated with changes in the quality of care and whether the size of bonus mattered.

METHODS AND FINDINGS

For this quasi-experimental study, we used a difference-in-differences approach combined with matching. We compared changes over time in the quality of care delivered by family health teams between (bonus) municipalities that chose to use some or all of the PMAQ money to provide performance-related bonuses to team workers with (nonbonus) municipalities that invested the funds using traditional input-based budgets. The primary outcome was the PMAQ score, a quality of care index on a scale of 0 to 100, based on several hundred indicators (ranging from 598 to 660) of health care delivery. We did one-to-one matching of bonus municipalities to nonbonus municipalities based on baseline demographic and economic characteristics. On the matched sample, we used ordinary least squares regression to estimate the association of any bonus and size of bonus with the prepost change over time (between November 2011 and October 2015) in the PMAQ score. We performed subgroup analyses with respect to the local area income of the family health team. The matched analytical sample comprised 2,346 municipalities (1,173 nonbonus municipalities; 1,173 bonus municipalities), containing 10,275 family health teams that participated in PMAQ from the outset. Bonus municipalities were associated with a 4.6 (95% CI: 2.7 to 6.4; p < 0.001) percentage point increase in the PMAQ score compared with nonbonus municipalities. The association with quality of care increased with the size of bonus: the largest bonus group saw an improvement of 8.2 percentage points (95% CI: 6.2 to 10.2; p < 0.001) compared with the control. The subgroup analysis showed that the observed improvement in performance was most pronounced in the poorest two-fifths of localities. The limitations of the study include the potential for bias from unmeasured time-varying confounding and the fact that the PMAQ score has not been validated as a measure of quality of care.

CONCLUSIONS

Performance bonuses to family health team workers compared with traditional input-based budgets were associated with an improvement in the quality of care.

Institutional Arrangements for Providing HIV and AIDS Services in Uganda: A Transaction Cost Economics Analysis

Transaction cost economics (TCE) theory predicts that features of institutional arrangements determine the intensity of their governance instruments. Consequently, institutional features link to transaction costs, but the linkages have received little attention in the public health literature. This study sought to address this gap. It examined the governance features of institutional arrangements and their transaction cost implications for providing HIV prevention and social support services in Uganda. The analysis was based on 4 proposed TCE governance instruments: administrative controls, adaptation, incentives and contract laws. These governance instruments were assessed in 3 modes of delivery( institutional arrangments) for HIV and AIDS Services in Uganda: Contracting-Out – the case of DREAMS (Determined, Resilient, Empowered, AIDS-free, Mentored and Safe); a Public-Non-Governmental Organisation (NGO) partnership – the case of the CHAI (Community-led HIV/AIDS Initiative); and direct Public Sector Delivery. These assessed delivery modes follow Williamson’s TCE framework of 3 institutional arrangements to deliver goods and services, notably market, hybrid (partnership) and internal (hierarchy) delivery, with related governance features. Within this framework, the discriminating alignment hypothesis guided the analysis. According to the hypothesis, the delivery modes of goods and services result in smaller transaction costs when their governance features are as predicted by TCE. The hypothesis was assessed by analysing, with qualitative methods, the differences in HIV and AIDS services characteristics across the 3 arrangements and their differences with theory prediction, and hence the difference in transaction cost implications. The study found that the delivery arrangements that minimised cost are those whose HIV and AIDS services were aligned with the TCE theory prediction. The aligned ‘public-NGO partnership’ arrangement (CHAI) had fewer sources of transactional costs than the misaligned arrangements – ‘contracting-out’ (DREAMS) and ‘public sector’. The analysis revealed that the DREAMS and public sector delivery models suffered some flaws in efficiencies. DREAMS had high administrative controls, high-powered tangible incentive intensity and intensive monitoring mechanisms for performance adaptation due to the lack of ‘trust’ on the part of the financing agency, contrary to the TCE prediction. In contrast with the TCE prediction, low administrative controls in the public sector arose from the failure to invest in performance monitoring systems. The high-powered incentive intensity and low administrative controls observed in the CHAI arrangement primarily stemmed from the reliance on informal institutions (trust, social expectations and reputation) rather than principal-agent arms-length sanctions. These results suggest that the level of transaction costs is associated with features of institutional arrangements. The valuable insights from TCE could contribute to policymaking during the design of institutional arrangements to efficiently deliver HIV and AIDS services.

The Effect of Network-Level Payment Models on Care Network Performance: A Scoping Review of the Empirical Literature

Introduction

Traditional payment models reward volume rather than value. Moving away from reimbursing separate providers to network-level reimbursement is assumed to support structural changes in health care organizations that are necessary to improve patient care. This scoping review evaluates the performance of care networks that have adopted network-level payment models.

Methods

A scoping review of the empirical literature was conducted according to the five-step York framework. We identified indicators of performance, categorized them in four categories (quality, utilization, spending and other consequences) and scored whether performance increased, decreased, or remained stable due to the payment model.

Results

The 76 included studies investigated network-level capitation, disease-based bundled payments, pay-for-performance and blended global payments. The majority of studies stem from the USA. Studies generally concluded that performance in terms of quality and utilization increased or remained stable. Most payment models were associated with improved spending performance. Overall, our review shows that network-level payment models are moderately successful in improving network performance.

Discussion/conclusion

As health care networks are increasingly common, it seems fruitful to continue experimenting with reimbursement models for health care networks. It is also important to broaden the scope to not only scrutinize outcomes, but also the contexts and mechanisms that lead to certain outcomes.

Physician Compensation Arrangements and Financial Performance Incentives in US Health Systems

Question

Do health system physician compensation arrangements primarily incentivize volume or value?

Findings

This cross-sectional mixed-methods study of 31 physician organizations affiliated with 22 US health systems found that volume was a component of primary care and specialist compensation for most POs (83.9% and 93.3%, respectively), representing a substantial portion of compensation when included (mean, 68.2% and 73.7%, respectively). While most primary care and specialist compensation arrangements included performance-based incentives, they averaged less than 10% of compensation.

Meaning

The study results suggest that despite growth in value-based payment arrangements from payers, health systems currently incentivize physicians to maximize volume, thereby maximizing health system revenues.

Importance

Public and private payers continue to expand use of alternative payment models, aiming to use value-based payment to affect the care delivery of their contracted health system partners. In parallel, health systems and their employment of physicians continue to grow. However, the degree to which health system physician compensation reflects an orientation toward value, rather than volume, is unknown.

Objective

To characterize primary care physician (PCP) and specialist compensation arrangements among US health system–affiliated physician organizations (POs) and measure the portion of total physician compensation based on quality and cost performance.

Design, Setting, and Participants

This study was a cross-sectional mixed-methods analysis of in-depth multimodal data (compensation document review, interviews with 40 PO leaders, and surveys conducted between November 2017 and July 2019) from 31 POs affiliated with 22 purposefully selected health systems in 4 states. Data were analyzed from June 2019 to September 2020.

Main Outcomes and Measures

The frequency of PCP and specialist compensation types and the percentage of compensation when included, including base compensation incentives, quality and cost performance incentives, and other financial incentives. The top 3 actions physicians could take to increase their compensation. The association between POs’ percentage of revenue from fee-for-service and their physicians’ volume-based compensation percentage.

Results

Volume-based compensation was the most common base compensation incentive component for PCPs (26 POs [83.9%]; mean, 68.2% of compensation; median, 81.4%; range, 5.0%-100.0% when included) and specialists (29 POs [93.3%]; mean, 73.7% of compensation; median, 90.5%; range, 2.5%-100.0% when included). While quality and cost performance incentives were common (included by 83.9%-56.7% of POs for PCPs and specialists, respectively), the percentage of compensation based on quality and cost performance was modest (mean, 9.0% [median, 8.3%; range, 1.0%-25.0%] for PCPs and 5.3% [median, 4.5%; range, 0.5%-16.0%] for specialists when included). Increasing the volume of services was the most commonly cited action for physicians to increase compensation, reported as the top action by 22 POs (70.0%) for PCPs and specialists. We observed a very weak, nonsignificant association between the percentage of revenue of POs from fee for service and the PCP and specialist volume-based compensation percentage (r = 0.08; P = .78 and r = −0.04; P = .89, respectively).

Conclusions and Relevance

The results of this cross-sectional study suggest that PCPs and specialists despite receiving value-based reimbursement incentives from payers, the compensation of health system PCPs and specialists was dominated by volume-based incentives designed to maximize health systems revenue.

Long-term effects of payment for performance on maternal and child health outcomes: evidence from Tanzania

BACKGROUND

The success of payment for performance (P4P) schemes relies on their ability to generate sustainable changes in the behaviour of healthcare providers. This paper examines short-term and longer-term effects of P4P in Tanzania and the reasons for these changes.

METHODS

We conducted a controlled before and after study and an embedded process evaluation. Three rounds of facility, patient and household survey data (at baseline, after 13 months and at 36 months) measured programme effects in seven intervention districts and four comparison districts. We used linear difference-in-difference regression analysis to determine programme effects, and differential effects over time. Four rounds of qualitative data examined evolution in programme design, implementation and mechanisms of change.

RESULTS

Programme effects on the rate of institutional deliveries and antimalarial treatment during antenatal care reduced overtime, with stock out rates of antimalarials increasing over time to baseline levels. P4P led to sustained improvements in kindness during deliveries, with a wider set of improvements in patient experience of care in the longer term. A change in programme management and funding delayed incentive payments affecting performance on some indicators. The verification system became more integrated within routine systems over time, reducing the time burden on managers and health workers. Ongoing financial autonomy and supervision sustained motivational effects in those aspects of care giving not reliant on funding.

CONCLUSION

Our study adds to limited and mixed evidence documenting how P4P effects evolve over time. Our findings highlight the importance of undertaking ongoing assessment of effects over time.

Perceptions of nurses and physicians on pay-for-performance in hospital: a systematic review of qualitative studies

AIMS

To systematically examine perceptions of nurses and physicians on pay-for-performance in hospital.

BACKGROUND

Pay-for-performance projects have proliferated over the past two decades, most systematic reviews of which solely focused on its effectiveness in primary healthcare and the physicians' or nurses' attitudes. However, systematic reviews of qualitative approaches for better examining perceptions of both nurses and physicians in hospital are lacking.

EVALUATION

Electronic databases were systematic searched with date from its inception to December 31, 2020. Meta-aggregation synthesis methodology and the conceptual framework of the Theory of Planned Behavior were used to summarize findings.

KEY ISSUES

A total of nine studies were included. Three major synthesized themes were identified: (1) perceptions of the motivation effects and positive outcomes (2) perceptions about the design defects and negative effects (3) perceptions of the obstacles in the implementation process.

CONCLUSION

To maximize the intended positive effects, nurses' and physicians' perceptions should be considered and incorporated into the project design and implementation stage.

IMPLICATIONS FOR NURSING MANAGEMENT AND RESEARCH

The paper gives enlightenment to nurse managers on improving and advancing the cause of nurses when planning for or evaluating their institutions' policies on pay-for-performance in the future research.

Orchestration versus bookkeeping: How stakeholder pressures drive a healthcare purchaser's institutional logics

Background

Healthcare purchasers such as health insurers and governmental bodies are expected to strategically manage chronic care chains. In doing so, purchasers can contribute to the goal of improving task division and collaboration between chronic care providers as has been recommended by numerous studies. However, healthcare purchasing research indicates that, in most countries, purchasers still struggle to fulfil a proactive, strategic approach. Consequently, a typical pattern occurs in which care improvement initiatives are instigated, but not transformed into regular care. By acknowledging that healthcare purchasers are embedded in a care chain of stakeholders who have different, sometimes conflicting, interests and, by taking an institutional logics lens, we seek to explain why achieving strategic purchasing and sustainable improvement is so elusive.

Method and findings

We present a longitudinal case study in which we follow a health insurer and care providers aiming to improve the care of patients with Chronic Obstructive Pulmonary Disease (COPD) in a region of the Netherlands. Taking a theoretical lens of institutional logics, our aim was to answer ‘how stakeholder pressures influence a purchaser’s use of institutional logics when pursuing the right care at the right place’. The insurer by default predominantly expressed a bookkeeper’s logic, reflecting a focus on controlling short-term care costs by managing individual providers. Over time, a contrasting orchestrator’s logic emerged in an attempt to achieve chain-wide improvement, striving for better health outcomes and lower long-term costs. We established five types of stakeholder pressure to explain the shift in logic adoption: relationship pressures, cost pressures, medical demands, public health demands and uncertainty. Linking the changes in logic over time with stakeholder pressures showed that, firstly, the different pressures interact in influencing the purchaser. Secondly, we saw that the lack of intra-organisational alignment affects how the purchaser deals with the different stakeholder pressures.

Conclusions

By highlighting the purchaser’s difficult position in the care chain and the consequences of their own internal responses, we now better understand why the intended orchestrator’s logic and thereby a strategic approach to purchasing chronic care proves unsustainable within the Dutch healthcare system of managed competition.

Allocation of health care under pay for performance: Winners and losers

Many physicians receive a payment for their performance (P4P). This performance is often linked to a health target that triggers a bonus when met. For some patients the target is easily met, while others require a significant amount of care to reach the target (if ever). This study contributes to the literature by providing evidence of how P4P affects allocation of care across patients with low and high responsiveness to treatment compared to a fixed payment, such as capitation and salary, under different degrees of resource constraint. Our evidence is based on a controlled laboratory experiment involving 143 medical students in Denmark in 2019. We find that patients who have the potential to reach the health target, gain care under P4P, whereas patients with no potential to reach it, may receive less care. Redistribution of care between patients under P4P arises when physicians are resource constrained. As many physicians are currently operating under tight resource constraints, policymakers should be careful to avoid unintended inequalities in patients' access to health care when introducing P4P. Risk-adjusting the performance target may potentially solve this issue.

Money matters - primary care providers' perceptions of payment incentives

PURPOSE

Payments to healthcare providers create incentives that can influence provider behaviour. Research on unit-level incentives in primary care is, however, scarce. This paper examines how managers and salaried physicians at Swedish primary healthcare centres perceive that payment incentives directed towards the healthcare centre affect their work.

DESIGN/METHODOLOGY/APPROACH

An interview study was conducted with 24 respondents at 13 primary healthcare centres in two cities, located in regions with different payment systems. One had a mixed system comprised of fee-for-service and risk-adjusted capitation payments, and the other a mainly risk-adjusted capitation system.

FINDINGS

Findings suggested that both managers and salaried physicians were aware of and adapted to unit-level payment incentives, albeit the latter sometimes to a lesser extent. Respondents perceived fee-for-service payments to stimulate production of shorter visits, up-coding of visits and skimming of healthier patients. Results also suggested that differentiated rates for patient visits affected horizontal prioritisations between physician and nurse visits. Respondents perceived that risk-adjustments for diagnoses led to a focus on registering diagnosis codes, and to some extent, also up-coding of secondary diagnoses.

PRACTICAL IMPLICATIONS

Policymakers and responsible authorities need to design payment systems carefully, balancing different incentives and considering how and from where data used to calculate payments are retrieved, not relying too heavily on data supplied by providers.

ORIGINALITY/VALUE

This study contributes evidence on unit-level payment incentives in primary care, a scarcely researched topic, especially using qualitative methods.

Employee Compensation Strategy as Sustainable Competitive Advantage for HR Education Practitioners

By building on compensation literature, the current study explored and identified the ties between workers’ competencies, corporate cultures, and compensation schemes. These schemes were typically the subject of literature on the factors dealing with the implementation of incentive systems for pay for performance (PFP) or problems that can lead to a PFP system’s failure. Unfortunately, when it comes to research that HR education practitioners may do, the literature has been scarce. It shows which organizational elements might be necessary to examine when deciding whether a PFP or an alternative compensation program is acceptable. This study aimed to add insight into this gap in research. The findings of this study showed from the use of data from 385 American employees in the manufacturing industry that there are significant relationships statistically between employee competencies and organizational cultures and those findings can be corroborated with existing researches, suggesting compensation schemes were related to multiple types of competence organizations and different organization cultures, thus adding meaningfully to the current literature.

Value-Based Provider Payment Initiatives Combining Global Payments With Explicit Quality Incentives: A Systematic Review

An essential element in the pursuit of value-based health care is provider payment reform. This article aims to identify and analyze payment initiatives comprising a specific manifestation of value-based payment reform that can be expected to contribute to value in a broad sense: (a) global base payments combined with (b) explicit quality incentives. We conducted a systematic review of the literature, consulting four scientific bibliographic databases, reference lists, the Internet, and experts. We included and compared 18 initiatives described in 111 articles/documents on key design features and impact on value. The initiatives are heterogeneous regarding the operationalization of the two payment components and associated design features. Main commonalities between initiatives are a strong emphasis on primary care, the use of "virtual" spending targets, and the application of risk adjustment and other risk-mitigating measures. Evaluated initiatives generally show promising results in terms of lower spending growth with equal or improved quality.

Perceptions of purchasing and payment mechanisms in alcohol and other drug treatment services in Australia: A qualitative study involving alcohol and other drug service providers and purchasers of treatment

INTRODUCTION AND AIMS

Governments across the globe invest considerable amounts in funding alcohol and other drug (AOD) treatment. Little attention however has been paid to the ways AOD service providers are chosen and how they are paid. This study sought to examine the perceptions of Australian AOD treatment purchasers and providers regarding different purchasing and payment mechanisms.

DESIGN AND METHODS

Qualitative interviews with AOD treatment providers and purchasers (N = 197) were undertaken across the eight Australian states/territories and the Commonwealth. Data were collated against six main AOD treatment purchasing and payment mechanisms (as identified in the literature), then an inductive, comparative analysis to assign codes was conducted, followed by interpretive analysis to explore emergent themes.

RESULTS

Five main themes were identified in relation to AOD treatment payment and purchasing mechanisms: (i) applying private sector principles to purchasing; (ii) innovation, sector stability and addressing client needs; (iii) performance monitoring and measuring outcomes; (iv) the threat to designated funding for AOD treatment; and (v) the costs and benefits of having multiple funding sources.

DISCUSSION AND CONCLUSIONS

In many countries reforms are taking place in the health sector consistent with New Public Management principles. These principles, when applied to AOD treatment, have included introducing competition, output and outcomes-based funding models, standards and accountability. Purchaser and providers identified both strengths and weaknesses and highlighted the overarching concern that implementation of any (mix) of these mechanisms should always be underpinned by a client-centred and not a finance-centred approach.

Health Care Professionals' Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis

Incentive-based pay-for-performance (P4P) models have been introduced during the last 2 decades as a mechanism to improve the delivery of evidence-based care that ensures clinical quality and improves health outcomes. There is mixed evidence that P4P has a positive effect on health outcomes and researchers cite lack of engagement from health care professionals as a limiting factor. This qualitative metasynthesis of existing qualitative research was conducted to integrate health care professionals’ perceptions of P4P in clinical practice. Four themes emerged during the research process: positive perceptions of the value of performance measurement and associated financial incentives; negative perceptions of the performance measurement and associated financial incentives; perceptions of how P4P programs influence the quality/appropriateness of care; and perceptions of the influence of P4P program on professional roles and workplace dynamics. Identifying factors that influence health care professionals’ perceptions about this type of value-based payment model will guide future research.

Effects of Monetary Incentives in Physician Groups: A Systematic Review of Reviews

BACKGROUND

Reimbursement systems that contribute to the cooperation and integration of providers have become increasingly important within the healthcare sector. Reimbursement systems not only serve as payment mechanisms but also provide control and incentive functions. Thus, the design of reimbursement systems is extremely important.

OBJECTIVES

The aims of this systematic review were to describe and gain a better understanding of the effects of monetary incentives in the setting of physician groups.

METHODS

In January 2020, we searched the MEDLINE (PubMed), Cochrane Library, CINAHL, PsycINFO, EconLit, and ISI Web of Science databases as well as the gray literature and authors' personal collections.

RESULTS

We included 21 reviews containing seven different incentive schemes/initiatives. The study settings and outcome measures varied considerably, as did the results within the incentive schemes and initiatives. However, we found positive effects on process quality for two types of incentives: pay-for-performance and accountable care organizations. The main limitations of this review were the variations in study settings and outcome measures of the studies included.

CONCLUSIONS

Monetary incentives in healthcare are often implemented as a control measure and are supposed to increase quality of care and reduce costs. The heterogeneity of the study results indicates that this is not always successful. The results reveal a need for research into the effects of monetary incentives in healthcare.

How are pay-for-performance schemes in healthcare designed in low- and middle-income countries? Typology and systematic literature review

BACKGROUND

Pay for performance (P4P) schemes provide financial incentives to health workers or facilities based on the achievement of pre-specified performance targets and have been widely implemented in health systems across low and middle-income countries (LMICs). The growing evidence base on P4P highlights that (i) there is substantial variation in the effect of P4P schemes on outcomes and (ii) there appears to be heterogeneity in incentive design. Even though scheme design is likely a key determinant of scheme effectiveness, we currently lack systematic evidence on how P4P schemes are designed in LMICs.

METHODS

We develop a typology to classify the design of P4P schemes in LMICs, which highlights different design features that are a priori likely to affect the behaviour of incentivised actors. We then use results from a systematic literature review to classify and describe the design of P4P schemes that have been evaluated in LMICs. To capture academic publications, Medline, Embase, and EconLit databases were searched. To include relevant grey literature, Google Scholar, Emerald Insight, and websites of the World Bank, WHO, Cordaid, Norad, DfID, USAID and PEPFAR were searched.

RESULTS

We identify 41 different P4P schemes implemented in 29 LMICs. We find that there is substantial heterogeneity in the design of P4P schemes in LMICs and pinpoint precisely how scheme design varies across settings. Our results also highlight that incentive design is not adequately being reported on in the literature - with many studies failing to report key design features.

CONCLUSIONS

We encourage authors to make a greater effort to report information on P4P scheme design in the future and suggest using the typology laid out in this paper as a starting point.

Opening the black box of diagnosis-related groups (DRGs): unpacking the technical remuneration structure of the Dutch DRG system

While we know that upcoding of diagnosis-related groups (DRGs) regularly occurs, we have little knowledge of the role of the technical features of coding systems in inducing coding behaviour. This paper presents methods for investigating the financial structure of the Dutch DRG system, and more in particular the grouper software, to gain such insight. The paper describes a system for investigating the robustness of the reward structure, by simulating the response of the DRG system to small changes in individual coding. The results from these analyses are used to visualise some data on coding behaviour, and to investigate how this behaviour is affected by incentives in the technical features of the DRG system. A number of technical weaknesses in the system are also identified.

Effects of pay-for-performance for primary care physicians on diabetes outcomes in single-payer health systems: a systematic review

BACKGROUND

Although pay-for-performance (P4P) for diabetes care is increasingly common, evidence of its effectiveness in improving population health and health system sustainability is deficient. This information gap is attributable in part to the heterogeneity of healthcare financing, covered medical conditions, care settings, and provider remuneration arrangements within and across countries. We systematically reviewed the literature concentrating on whether P4P for physicians in primary and community care leads to better diabetes outcomes in single-payer national health insurance systems.

METHODS

Studies were identified by searching ten databases (01/2000-04/2018) and scanning the reference lists of review articles and other global health literature. We included primary studies evaluating the effects of introducing P4P for diabetes care among primary care physicians in countries of universal health coverage. Outcomes of interest included patient morbidity, avoidable hospitalization, premature death, and healthcare costs.

RESULTS

We identified 2218 reports; after exclusions, 10 articles covering 8 P4P interventions in 7 countries were eligible for analysis. Five studies, capturing records from 717,166 patients with diabetes, were graded as high-quality evaluations of P4P on health outcomes. Based on three quality studies, P4P can result in reduced risk of mortality over the longer term-when linked to performance metrics. However, studies from other jurisdictions, where P4P was not linked to specific patient-oriented objectives, yielded little or mixed evidence of positive health impacts.

CONCLUSION

Evidence of the effectiveness of P4P depends on whether physicians' incentive payments are explicitly tied to performance metrics. However, the most appropriate indicators for performance monitoring remain in question. More research with rigorous evaluation in different settings is needed.

Predicting Length of Stay and the Need for Postacute Care After Acute Myocardial Infarction to Improve Healthcare Efficiency

Background To improve value in the care of patients with acute myocardial infarction (MI), payment models increasingly hold providers accountable for costs. As such, providers need tools to predict length of stay (LOS) during hospitalization and the likelihood of needing postacute care facilities after discharge for acute MI patients. We developed models to estimate risk for prolonged LOS and postacute care for acute MI patients at time of hospital admission to facilitate coordinated care planning. Methods and Results We identified patients in the National Cardiovascular Data Registry ACTION registry (Acute Coronary Treatment and Intervention Outcomes Network) who were discharged alive after hospitalization for acute MI between July 1, 2008 and March 31, 2017. Within a 70% random sample (Training cohort) we developed hierarchical, proportional odds models to predict LOS and hierarchical logistic regression models to predict discharge to postacute care. Models were validated in the remaining 30%. Of 633 737 patients in the Training cohort, 16.8% had a prolonged LOS (≥7 days) and 7.8% were discharged to a postacute facility (extended care, a transitional care unit, or rehabilitation). Model discrimination was moderate in the validation dataset for predicting LOS (C statistic=0.640) and strong for predicting discharge to postacute care (C statistic=0.827). For both models, discrimination was similar in ST-segment-elevation MI and non-ST-segment-elevation MI subgroups and calibration was excellent. Conclusions These models developed in a national registry can be used at the time of initial hospitalization to predict LOS and discharge to postacute facilities. Prospective testing of these models is needed to establish how they can improve care coordination and lower costs.

2019 Diabetes Atlas: Achievements and challenges in diabetes care in Taiwan

The 2019 Diabetes Atlas delineated both accomplishments and challenges in diabetes care in Taiwan between 2005 and 2014. The series reported that Taiwan had significantly improved aspects of care quality for patients with diabetes. For example, the mortality rate decreased, the difference between the life expectancies of patients with diabetes and those of the general population decreased, and the rates of hospitalization because of heart diseases, cerebrovascular diseases, chronic kidney diseases, and unsatisfactory glycemic control decreased. However, despite these achievements, the 2019 Diabetes Atlas also reported some substantial challenges that have not been overcome. For example, the incidence of diabetes among women aged <19 years and 20-39 years increased by 27% and 33%, respectively. Furthermore, a high prevalence of macrovascular complications, a continuous increase in the dialysis prevalence rates among men with diabetes of all ages, and a low participation rate (<20%) of patients with diabetes in the pay-for-performance program were observed. The publication of the 2019 Diabetes Atlas is a milestone that demonstrates a strong will in medical societies to improve the quality of diabetes care. We expect this initiative can be reorganized every 5 years to report the results of continuous monitoring and surveillance and update the epidemiological features of diabetes in Taiwan.

[Entre dynamique d'amélioration de la qualité des soins et conformisme administratif : comportements des établissements de santé français face au paiement à la performance (P4P)]

Le paiement à la performance (P4P) continue de se développer dans les systèmes de santé des pays industrialisés, malgré des preuves encore assez limitées de son efficacité. Cette étude propose de comprendre le comportement des établissements de santé face à ce nouveau mode de paiement en se basant sur l'expérimentation de P4P hospitalier conduite en France. Nous avons, pour cela, combiné une approche quantitative basée sur un questionnaire auprès des établissements participants et une analyse qualitative dans neuf établissements afin de mieux identifier les processus à l'œuvre. L'étude montre que des actions correctives ont été réalisées dans certains établissements mais que les effets du programme sur l'organisation restent en fait assez limités puisqu'ils s'opèrent davantage à la marge. Les comportements semblent être essentiellement le reflet d'une volonté de conformation des organisations aux attentes de la tutelle, sans transformations organisationnelles majeures. Il sera toutefois intéressant de voir comment des perceptions différentes structurent ces comportements sur le long terme.

Does payment for performance increase performance inequalities across health providers? A case study of Tanzania

The impact of payment-for-performance (P4P) schemes in the health sector has been documented, but there has been little attention to the distributional effects of P4P across health facilities. We examined the distribution of P4P payouts over time and assessed whether increased service coverage due to P4P differed across facilities in Tanzania. We used two service outcomes that improved due to P4P [facility-based deliveries and provision of antimalarials during antenatal care (ANC)], to also assess whether incentive design matters for performance inequalities. We used data from 150 facilities from intervention and comparison areas in January 2012 and 13 months later. Our primary data were gathered through facility survey and household survey, while data on performance payouts were obtained from the programme administrator. Descriptive inequality measures were used to examine the distribution of payouts across facility subgroups. Difference-in-differences regression analyses were used to identify P4P differential effects on the two service coverage outcomes across facility subgroups. We found that performance payouts were initially higher among higher-level facilities (hospitals and health centres) compared with dispensaries, among facilities with more medical commodities and among facilities serving wealthier populations, but these inequalities declined over time. P4P had greater effects on coverage of institutional deliveries among facilities with low baseline performance, serving middle wealth populations and located in rural areas. P4P effects on antimalarials provision during ANC was similar across facilities. Performance inequalities were influenced by the design of incentives and a range of facility characteristics; however, the nature of the service being targeted is also likely to have affected provider response. Further research is needed to examine in more detail the effects of incentive design on outcomes and researchers should be encouraged to report on design aspects in their evaluations of P4P and systematically monitor and report subgroup effects across providers.

Design and effects of outcome-based payment models in healthcare: a systematic review

INTRODUCTION

Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects.

METHODS

We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs.

RESULTS

We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth.

DISCUSSION

Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.

(How) does RBF strengthen strategic purchasing of health care? Comparing the experience of Uganda, Zimbabwe and the Democratic Republic of the Congo

BACKGROUND

Results-Based Financing (RBF) has proliferated in health sectors of low and middle income countries, especially fragile and conflict-affected ones, and has been presented as a way of reforming and strengthening strategic purchasing. However, few studies have empirically examined how RBF impacts on health care purchasing in these settings. This article examines the effects of several RBF programmes on health care purchasing functions in three fragile and post-conflict settings: Uganda, Zimbabwe and the Democratic Republic of Congo (DRC) over the past decade.

METHODS

The article is based on a documentary review, including 110 documents from 2004 to 2018, and 98 key informant (KI) interviews conducted with international, national and district level stakeholders in early 2018 in the selected districts of the three countries. Interviews and analysis followed an adapted framework for strategic purchasing, which was also used to compare across the case studies.

RESULTS

Across the cases, at the government level, we find little change to the accountability of purchasers, but RBF does mobilise additional resources to support entitlements. In relation to the population, RBF appears to bring in improvements in specifying and informing about entitlements for some services. However, the engagement and consultation with the population on their needs was found to be limited. In relation to providers, RBF did not impact in any major way on provider accreditation and selection, or on treatment guidelines. However, it did introduce a more contractual relationship for some providers and bring about (at least partial) improvements in provider payment systems, data quality, increased financial autonomy for primary providers and enforcing equitable strategies. More generally, RBF has been a source of much-needed revenue at primary care level in under-funded health systems. The context - particularly the degree of stability and authority of government-, the design of the RBF programme and the potential for effective integration of RBF in existing systems and its stage of development were key factors behind differences observed.

CONCLUSIONS

Our evidence suggests that expectations of RBF as an instrument of systemic reform should be nuanced, while focusing instead on expanding the key areas of potential gain and ensuring better integration and institutionalisation, towards which two of the three case study countries are working.

The challenges of the family physician policy in Iran: a systematic review and meta-synthesis of qualitative researches

BACKGROUND

A good level of health requires the establishment of primary health care. Family physician policy (FPP) is probably one of such initiatives, which enables societies attaining the universal health coverage.

OBJECTIVE

The present study is the first systematic review and meta-synthesis that seeks to provide a more comprehensive understanding of the challenges for FPP in Iran.

METHOD

Several international scholarly databases (namely, ISI/Web of Sciences, PubMed/MEDLINE via Ovid, Embase, PsycINFO, Scopus and CINAHL via EBSCO), as well as three Iranian databases [MagIran, Irandoc and Scientific Information Database (SID) databases], were mined from January 2006 to December 2017. The Noblit & Hare approach was used to analyse the selected studies.

RESULTS

Based on the study inclusion criteria, seven studies were retained. Initially, 133 codes were identified. In the second step, two of the authors examined the codes and merged themes based on their similarities and shared meaning. New codes were created through discussion. In the next and final step, eight themes emerged, namely, (i) financing; (ii) motivational factors; (iii) education; (iv) referral system; (v) performance evaluation; (vi) problems with health policy; (vii) health information system; and (viii) culture-building for proper policy implementation.

CONCLUSION

Although more than 10 years have passed since the implementation of FPP in Iran, and despite its positive effects on health, there are still challenges in implementing this policy, which makes it difficult to achieve its objectives. Health decision- and policy-makers in Iran should address these challenges and use all available capacities to face them.

Impact of Medicare's Nonpayment Program on Venous Thromboembolism Following Hip and Knee Replacements

OBJECTIVE

To determine whether Medicare's Nonpayment Program was associated with decline in venous thromboembolism (VTE) following hip and knee replacements; and whether the decline was greater among hospitals at risk of larger financial losses from the Program.

DATA SOURCES

State Inpatient Database for New York (NY) from 2005 to 2013.

STUDY DESIGN

The primary outcome was an occurrence of VTE. Medicare Utilization Ratio (MUR), which is the proportion of inpatient days in a hospital that is financed by Medicare, represented a hospital's financial sensitivity. We used hierarchical logistic regressions with difference-in-differences estimation to study the Program effects.

PRINCIPAL FINDINGS

A total of 98,729 hip replacement and 111,361 knee replacement stays were identified. For hip replacement, the Program was associated with significant reduction (Range: 44% to 53%) in VTE incidence among hospitals in MUR quartiles 2 to 4. For knee replacement, the Program was associated with significant reduction (47%) in VTE incidence only among quartile 2 hospitals.

CONCLUSION

Implementation of the Program was associated with a reduction in VTE, especially for hip replacements, in higher MUR hospitals. Payment reforms such as Medicare's Nonpayment Program that withhold payments for complications are effective and should be continued.

Uncertainty about the effort-performance relationship in threshold-based payment schemes

Incentive schemes often feature a threshold beyond which providers receive no additional payment for performance. We investigate whether providers' uncertainty about the relationship between effort and measured performance leads to financially unrewarded performance in such schemes. Using data from the British Quality and Outcomes Framework, we proxy general practitioners' uncertainty about the effort-performance relationship by their experience with the scheme and their span of control. We find evidence that providers respond to uncertainty by exerting financially unrewarded performance, suggesting that uncertainty may be a mechanism by which payers can extract unrewarded performance.

Physicians' and nurses' attitudes towards performance-based financial incentives in Burundi: a qualitative study in the province of Gitega

Background: Performance-based financing (PBF) was first implemented in Burundi in 2006 as a pilot programme in three provinces and was rolled out nationwide in 2010. PBF is a reform approach to improve the quality, quantity, and equity of health services and aims at achieving universal health coverage. It focuses on how to best motivate health practitioners.

Objective: To elicit physicians’ and nurses’ experiences and views on how PBF influenced and helped them in healthcare delivery.

Methods: A qualitative cross-sectional study was carried out among frontline health workers such as physicians and nurses. The data was gathered through individual face-to-face, in-depth, semi-structured interviews with 6 physicians and 30 nurses from February to March 2011 in three hospitals in Gitega Province. A simple framework approach and thematic analysis using a combination of manual technique and MAXQDA software guided the analysis of the interview data.

Results: Overall, the interviewees felt that the PBF scheme had provided positive motivation to improve the quality of care, mainly in the structures and process of care. The utilization of health services and the relationship between health practitioners and patients also improved. The salary top-ups were recognized as the most significant impetus to increase effort in improving the quality of care. The small and sometimes delayed financial incentives paid to physicians and nurses were criticized. The findings of this study also indicate that the positive interaction between performance-based incentive schemes and other health policies is crucial in achieving comprehensive improvement in healthcare delivery.

Conclusions: PBF has the potential to motivate medical staff to improve healthcare provision. The views of medical staff and the context of the area of implementation have to be taken into consideration when designing and implementing PBF schemes.

Improvement of the quality payment program by improving data reporting process: an action research

BACKGROUND

Successful implementation of pay-for-quality (P4Q) programs mostly depends upon a valid, timely, and reliable data about quality measures generated by providers, and interpreted by payers. The aim of this study was to establish a data reporting method for P4Q program through an action research.

METHODS

Qualitative method was used to align theory with action through a three-cycle action research. The study was conducted in September 15, 2015 to March 15, 2017, in East-Azerbaijan, Iran. The purposeful sampling was used to select participants. The participants included healthcare providers, staff in district health centers (DHC), experts, and managers in the provincial primary health center (PPHC). Data was collected by interviews, focus group discussions, and expert panels. Content analysis was used to synthesize the data. In each step, decisions about data reporting methods were made through a consensus of expert panel members.

RESULTS

The most important dimensions of data reporting method were data entry and accuracy, data reporting, data analysis and interpretations, the flexibility of method, and training. By establishment of an online data reporting system for the P4Q program, a major improvement was observed in the documentation of performance data, the satisfaction of health care providers and staff (e.g. either in DHCs or PPHC), improvement of the P4Q program and acceptance of the P4Q program by providers. Following the present study, the online system was expanded in Iran's public health system for data collection and estimating the amount of incentive payments in P4Q program. Moreover, more improvements were achieved by linking the system to EMRs and also, providing automated feedback to providers about their own performance.

CONCLUSIONS

A web-based computerized system with the capability of linking medical record and also its ability to provide feedback to healthcare providers was identified as an appropriate method of data reporting in the P4Q program from the viewpoints of participants in this study.