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McManus E, Elliott J, Meacock R, Wilson P, Gellatly J, Sutton M. The effects of structure, process and outcome incentives on primary care referrals to a national prevention programme. HEALTH ECONOMICS 2021; 30:1393-1416. [PMID: 33786914 DOI: 10.1002/hec.4262] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 02/09/2021] [Accepted: 02/17/2021] [Indexed: 06/12/2023]
Abstract
Despite widespread use, evidence is sparse on whether financial incentives in healthcare should be linked to structure, process or outcome. We examine the impact of different incentive types on the quantity and effectiveness of referrals made by general practices to a new national prevention programme in England. We measured effectiveness by the number of referrals resulting in programme attendance. We surveyed local commissioners about their use of financial incentives and linked this information to numbers of programme referrals and attendances from 5170 general practices between April 2016 and March 2018. We used multivariate probit regressions to identify commissioner characteristics associated with the use of different incentive types and negative binomial regressions to estimate their effect on practice rates of referral and attendance. Financial incentives were offered by commissioners in the majority of areas (89%), with 38% using structure incentives, 69% using process incentives and 22% using outcome incentives. Compared to practices without financial incentives, neither structure nor process incentives were associated with statistically significant increases in referrals or attendances, but outcome incentives were associated with 84% more referrals and 93% more attendances. Outcome incentives were the only form of pay-for-performance to stimulate more participation in this national disease prevention programme.
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Affiliation(s)
- Emma McManus
- Health Organisation, Policy and Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Services, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Jack Elliott
- Health Organisation, Policy and Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Services, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Rachel Meacock
- Health Organisation, Policy and Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Services, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Paul Wilson
- Centre for Primary Care and Health Services Research, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Judith Gellatly
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Services, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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Feng Y, Kristensen SR, Lorgelly P, Meacock R, Sanchez MR, Siciliani L, Sutton M. Pay for performance for specialised care in England: Strengths and weaknesses. Health Policy 2019; 123:1036-1041. [PMID: 31405615 DOI: 10.1016/j.healthpol.2019.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 05/29/2019] [Accepted: 07/09/2019] [Indexed: 11/25/2022]
Abstract
Pay-for-Performance (P4P) schemes have become increasingly common internationally, yet evidence of their effectiveness remains ambiguous. P4P has been widely used in England for over a decade both in primary and secondary care. A prominent P4P programme in secondary care is the Commissioning for Quality and Innovation (CQUIN) framework. The most recent addition to this framework is Prescribed Specialised Services (PSS) CQUIN, introduced into the NHS in England in 2013. This study offers a review and critique of the PSS CQUIN scheme for specialised care. A key feature of PSS CQUIN is that whilst it is centrally developed, performance targets are agreed locally. This means that there is variation across providers in the schemes selected from the national menu, the achievement level needed to earn payment, and the proportion of the overall payment attached to each scheme. Specific schemes vary in terms of what is incentivised - structure, process and/or outcome - and how they are incentivised. Centralised versus decentralised decision making, the nature of the performance measures, the tiered payment structure and the dynamic nature of the schemes have created a sophisticated but complex P4P programme which requires evaluation to understand the effect of such incentives on specialised care.
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Affiliation(s)
- Yan Feng
- Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AB, London, UK
| | - Søren Rud Kristensen
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, SW7 2A, London, UK
| | - Paula Lorgelly
- Office of Health Economics, SW1E 6QT, London, UK; Faculty of Life Sciences and Medicine, King's College London, WC2R 2LS, London, UK
| | - Rachel Meacock
- School of Health Sciences, University of Manchester, M13 9PL, Manchester, UK
| | | | - Luigi Siciliani
- Department of Economics and Related Studies, University of York, YO10 5DD, York, UK.
| | - Matt Sutton
- School of Health Sciences, University of Manchester, M13 9PL, Manchester, UK
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Larsen KN, Kristensen SR, Søgaard R. Autonomy to health care professionals as a vehicle for value-based health care? Results of a quasi-experiment in hospital governance. Soc Sci Med 2017; 196:37-46. [PMID: 29127851 DOI: 10.1016/j.socscimed.2017.11.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 11/02/2017] [Accepted: 11/04/2017] [Indexed: 10/18/2022]
Abstract
Health care systems increasingly aim to create value for money by simultaneous incentivizing of quality along with classical goals such as activity increase and cost containment. It has recently been suggested that letting health care professionals choose the performance metrics on which they are evaluated may improve value of care by facilitating greater employee initiative, especially in the quality domain. There is a risk that this strategy leads to loss of performance as measured by the classical goals, if these goals are not prioritized by health care professionals. In this study we investigate the performance of eight hospital departments in the second largest region of Denmark that were delegated the authority to choose their own performance focus during a three-year test period from 2013 to 2016. The usual activity-based remuneration was suspended and departments were instructed to keep their global budgets and maintain activity levels, while managing according to their newly chosen performance focuses. Our analysis is based on monthly observations from two years before to three years after delegation. We collected data for 32 new performance indicators chosen by hospital department managements; 11 new performance indicators chosen by a centre management under which 5 of the departments were organised; and 3 classical indicators of priority to the central administration (activity, productivity, and cost containment). Interrupted time series analysis is used to estimate the effect of delegation on these indicators. We find no evidence that this particular proposal for giving health care professionals greater autonomy leads to consistent quality improvements but, on the other hand, also no consistent evidence of harm to the classical goals. Future studies could consider alternative possibilities to create greater autonomy for hospital departments.
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Affiliation(s)
- Kristian Nørgaard Larsen
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus, Denmark; Health Economics, DEFACTUM, Central Denmark Region, Olof Palmes Allé 15, 8200 Aarhus, Denmark
| | - Søren Rud Kristensen
- Manchester Centre for Health Economics, The University of Manchester, Oxford Road, M13 9PL Manchester, UK
| | - Rikke Søgaard
- Department of Public Health, Aarhus University, Bartholins Allé 2, 8000 Aarhus, Denmark.
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