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Ride J, Kasteridis P, Gutacker N, Gravelle H, Rice N, Mason A, Goddard M, Doran T, Jacobs R. Impact of prevention in primary care on costs in primary and secondary care for people with serious mental illness. HEALTH ECONOMICS 2023; 32:343-355. [PMID: 36309945 PMCID: PMC10092448 DOI: 10.1002/hec.4623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 06/16/2023]
Abstract
A largely unexplored part of the financial incentive for physicians to participate in preventive care is the degree to which they are the residual claimant from any resulting cost savings. We examine the impact of two preventive activities for people with serious mental illness (care plans and annual reviews of physical health) by English primary care practices on costs in these practices and in secondary care. Using panel two-part models to analyze patient-level data linked across primary and secondary care, we find that these preventive activities in the previous year are associated with cost reductions in the current quarter both in primary and secondary care. We estimate that there are large beneficial externalities for which the primary care physician is not the residual claimant: the cost savings in secondary care are 4.7 times larger than the cost savings in primary care. These activities are incentivized in the English National Health Service but the total financial incentives for primary care physicians to participate were considerably smaller than the total cost savings produced. This suggests that changes to the design of incentives to increase the marginal reward for conducting these preventive activities among patients with serious mental illness could have further increased welfare.
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Affiliation(s)
- Jemimah Ride
- Health Economics UnitMelbourne School of Population and Global HealthUniversity of MelbourneParkvilleVictoriaAustralia
| | | | | | | | - Nigel Rice
- Centre for Health EconomicsUniversity of YorkYorkUK
| | - Anne Mason
- Centre for Health EconomicsUniversity of YorkYorkUK
| | | | - Tim Doran
- Health SciencesUniversity of YorkYorkUK
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Waitzberg R, Gottlieb N, Quentin W, Busse R, Greenberg D. Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations? Int J Health Policy Manag 2022; 11:1823-1834. [PMID: 34634873 PMCID: PMC9808238 DOI: 10.34172/ijhpm.2021.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 07/17/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hospital professionals are "dual agents" who may face dilemmas between their commitment to patients' clinical needs and hospitals' financial sustainability. This study examines whether and how hospital professionals balance or reconcile clinical and economic considerations in their decision-making in two countries with activity-based payment systems. METHODS We conducted 46 semi-structured interviews with hospital managers, chief physicians and practicing physicians in five German and five Israeli hospitals in 2018/2019. We used thematic analysis to identify common topics and patterns of meaning. RESULTS Hospital professionals report many situations in which activity-based payment incentivizes proper treatment, and clinical and economic considerations are aligned. This is the case when efficiency can be improved, eg, by curbing unnecessary expenditures or specializing in certain procedures. When considerations are misaligned, hospital professionals have developed a range of strategies that may contribute to balancing competing considerations. These include 'reshaping management,' such as better planning of the entire course of treatment and improvement of the coding; and 'reframing decision-making,' which involves working with averages and developing tool-kits for decision-making. CONCLUSION Misalignment of economic and clinical considerations does not necessarily have negative implications, if professionals manage to balance and reconcile them. Context is important in determining if considerations can be reconciled or not. Reconciling strategies are fragile and can be easily disrupted depending on context. Creating tool-kits for better decision-making, planning the treatment course in advance, working with averages, and having interdisciplinary teams to think together about ways to improve efficiency can help mitigate dilemmas of hospital professionals.
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Affiliation(s)
- Ruth Waitzberg
- The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem, Israel
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
| | - Nora Gottlieb
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Wilm Quentin
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Reinhard Busse
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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Fankhänel T, Panic BJ, Schwarz M, Schulz K, Frese T. Treating Excessive Consumers With Brief Intervention to Reduce Their Alcohol Consumption. EUROPEAN JOURNAL OF HEALTH PSYCHOLOGY 2021. [DOI: 10.1027/2512-8442/a000079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Abstract. Background: General Practitioners’ (GP) readiness to implement screening and brief intervention to reduce alcohol consumption of excessive consumers is low. Although several barriers were identified by past research, improving these conditions has not led to improved implementation. Based on Expectancy Value Theory of Achievement Motivation we assume that low seriousness of the health problem in association with the treatment of excessive alcohol consumers may be considered as a crucial barrier too. Aims: By our study, we tested for the influence of the seriousness of the health problem on the GP’s readiness to implement brief intervention (BI) in comparison to crucial barriers such as insufficient financial reimbursement and low patient adherence. Method: In order to manipulate the seriousness of the health problem GPs were confronted with three different situations each introducing a fictitious patient with either excessive alcohol consumption, or binge drinking, or harmful alcohol consumption. Results: Questionnaires of 185 GPs were analyzed. As hypothesized GPs were less ready to treat patients with excessive consumption in comparison to patients with harmful consumption, t(184) = 5.51, p < .001, d = .40, and binge drinking, t(184) = 6.14, p < .001, d = .43. Their readiness was higher in case of high adherence, F(1, 181) = 17.35, p < .001, η2 = .09. Limitations: Recruitment of GPs was based on voluntary participation. GPs had to assess their readiness in the artificial context of case vignettes. Conclusion: GPs’ readiness to implement a BI was influenced by the seriousness of the health problem and expected patient adherence. No such effect was found for financial reimbursement.
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Affiliation(s)
- Thomas Fankhänel
- Institute for General Practice and Family Medicine, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle, Germany
- Department of Health Psychology, SRH University of Applied Health Science, Gera, Germany
| | - Benjamin Jovan Panic
- Department of Health Psychology, SRH University of Applied Health Science, Gera, Germany
| | - Marcus Schwarz
- Department of Health Psychology, SRH University of Applied Health Science, Gera, Germany
| | - Katrin Schulz
- Department of Health Psychology, SRH University of Applied Health Science, Gera, Germany
| | - Thomas Frese
- Institute for General Practice and Family Medicine, Medical Faculty, Martin-Luther-University Halle-Wittenberg, Halle, Germany
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Behavioral Economics: A Primer and Applications to the UN Sustainable Development Goal of Good Health and Well-Being. REPORTS 2021. [DOI: 10.3390/reports4020016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Behavioral economics (BE) is a relatively new field within economics that incorporates insights from psychology that can be harnessed to improve economic decision making with the potential to enhance good health and well-being of individuals and societies, the third of the United Nations Sustainable Development Goals. While some of the psychological principles of economic decision making were described as far back as the 1700s by Adam Smith, BE emerged as a discipline in the 1970s with the groundbreaking work of psychologists Daniel Kahneman and Amos Tversky. We describe the basic concepts of BE, heuristics (decision-making shortcuts) and their associated biases, and the BE strategies framing, incentives, and economic nudging to overcome these biases. We survey the literature to identify how BE techniques have been employed to improve individual choice (focusing on childhood obesity), health policy, and patient and healthcare provider decision making. Additionally, we discuss how these BE-based efforts to improve health-related decision making can lead to sustaining good health and well-being and identify additional health-related areas that may benefit from including principles of BE in decision making.
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Swedberg K, Cawley D, Ekman I, Rogers HL, Antonic D, Behmane D, Björkman I, Britten N, Buttigieg SC, Byers V, Börjesson M, Corazzini K, Fors A, Granger B, Joksimoski B, Lewandowski R, Sakalauskas V, Srulovici E, Törnell J, Wallström S, Wolf A, Lloyd HM. Testing cost containment of future healthcare with maintained or improved quality-The COSTCARES project. Health Sci Rep 2021; 4:e309. [PMID: 34141903 PMCID: PMC8180514 DOI: 10.1002/hsr2.309] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Revised: 04/24/2021] [Accepted: 05/06/2021] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Increasing healthcare costs need to be contained in order to maintain equality of access to care for all EU citizens. A cross-disciplinary consortium of experts was supported by the EU FP7 research programme, to produce a roadmap on cost containment, while maintaining or improving the quality of healthcare. The roadmap comprises two drivers: person-centred care and health promotion; five critical enablers also need to be addressed: information technology, quality measures, infrastructure, incentive systems, and contracting strategies. METHOD In order to develop and test the roadmap, a COST Action project was initiated: COST-CARES, with 28 participating countries. This paper provides an overview of evidence about the effects of each of the identified enablers. Intersections between the drivers and the enablers are identified as critical for the success of future cost containment, in tandem with maintained or improved quality in healthcare. This will require further exploration through testing. CONCLUSION Cost containment of future healthcare, with maintained or improved quality, needs to be addressed through a concerted approach of testing key factors. We propose a framework for test lab design based on these drivers and enablers in different European countries.
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Affiliation(s)
- Karl Swedberg
- Centre for Person Centred CareUniversity of GothenburgGothenburgSweden
- Department of Molecular and Clinical MedicineUniversity of GothenburgGothenburgSweden
| | - Desmond Cawley
- Department of Nursing and Healthcare, Faculty of Science and HealthAthlone Institute of TechnologyAthloneIreland
| | - Inger Ekman
- Centre for Person Centred CareUniversity of GothenburgGothenburgSweden
- Institute of Health and Care SciencesUniversity of GothenburgGothenburgSweden
| | - Heather L. Rogers
- Biocruces Bizkaia Health Research InstituteBarakaldoSpain
- Ikerbasque Basque Foundation for ScienceBilbaoSpain
| | | | - Daiga Behmane
- Institute of Public HealthRiga Stradins UniversityRigaLatvia
| | - Ida Björkman
- Centre for Person Centred CareUniversity of GothenburgGothenburgSweden
- Institute of Health and Care SciencesUniversity of GothenburgGothenburgSweden
| | - Nicky Britten
- Institute of Health and Care SciencesUniversity of GothenburgGothenburgSweden
- College of Medicine and HealthUniversity of Exeter Medical SchoolExeterUK
| | - Sandra C. Buttigieg
- Department of Health Services Management, Faculty of Health SciencesUniversity of MaltaMsidaMalta
| | - Vivienne Byers
- Environmental Sustainability & Health InstituteTechnological University DublinDublinIreland
| | - Mats Börjesson
- Department of Neuroscience and PhysiologyUniversity of GothenburgGothenburgSweden
- Department of Food, Nutrition and Sports Science, Center for Health and PerformanceUniversity of GothenburgGothenburgSweden
| | - Kirsten Corazzini
- Duke University School of NursingDurhamNorth Carolina
- Duke University Center for the Study of Aging and Human DevelopmentDurhamNorth Carolina
| | - Andreas Fors
- Centre for Person Centred CareUniversity of GothenburgGothenburgSweden
- Institute of Health and Care SciencesUniversity of GothenburgGothenburgSweden
| | - Bradi Granger
- Duke University Heart and Vascular ServicesDurhamNorth Carolina
| | - Boban Joksimoski
- Faculty of Computer Science and EngineeringSkopjeNorth Macedonia
| | - Roman Lewandowski
- Management FacultyUniversity of Social SciencesLodzPoland
- Voivodeship Rehabilitation Hospital for Children in AmerykaOlsztynekPoland
| | | | | | - Jan Törnell
- Centre for Person Centred CareUniversity of GothenburgGothenburgSweden
- Department of Neuroscience and PhysiologyUniversity of GothenburgGothenburgSweden
| | - Sara Wallström
- Centre for Person Centred CareUniversity of GothenburgGothenburgSweden
- Institute of Health and Care SciencesUniversity of GothenburgGothenburgSweden
| | - Axel Wolf
- Centre for Person Centred CareUniversity of GothenburgGothenburgSweden
- Institute of Health and Care SciencesUniversity of GothenburgGothenburgSweden
| | - Helen M. Lloyd
- Faculty of Health and Human Sciences, School of PsychologyUniversity of PlymouthPlymouthUnited Kingdom
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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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Abstract
BACKGROUND From November 2014 to May 2016, 57 local health departments in New York State (NYS) excluding New York City were offered a performance incentive (PI) to promote adherence to federally recommended treatment guidelines for gonorrhea. The rationale of the PI was to delay antibiotic resistance and disrupt transmission through attaining a high percentage of treatment adherence. METHODS Surveillance data from the NYS Communicable Disease Electronic Surveillance System were used for analysis. We evaluated adherence per Centers for Disease Control and Prevention sexually transmitted diseases treatment guidelines for persons 12 years and older reported with uncomplicated gonorrhea during 4 time frames: Pre-PI, PI One, PI Two, and Post-PI. We measured adherence per the Centers for Disease Control and Prevention sexually transmitted disease treatment guidelines during each respective time frame and conducted χ tests to test for the association between treatment adequacy and time frame. RESULTS During the Pre-PI, treatment was adequate in 82.0% of persons diagnosed with gonorrhea. After program implementation, treatment adequacy increased significantly (92.1% of diagnosed persons during PI One, 90.4% during PI Two, and 90.5% during the Post-PI; P ≤ 0.0001). The most common reason for inadequate or missing treatment was patient lost to follow-up. CONCLUSIONS Public health intervention by the NYS Department of Health improved local health department adherence to federally recommended gonorrhea treatment guidelines, and improvements were maintained after the completion of the PI.
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Fankhaenel T, Schulz K, Petersen LE, Klement A, Frese T. Financial reimbursement - irrelevant for GPs' readiness to implement brief intervention to reduce alcohol consumption? A cross-sectional vignette study. BMC FAMILY PRACTICE 2020; 21:170. [PMID: 32814561 PMCID: PMC7439686 DOI: 10.1186/s12875-020-01231-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 07/22/2020] [Indexed: 11/14/2022]
Abstract
Background General Practitioners’ (GPs) readiness to implement screening and brief intervention (SBI) to treat patients with excessive alcohol consumption is low. Several studies identified crucial barriers such as insufficient financial reimbursement. In contrast to the barriers-account, we assume that low implementation readiness of GPs may be less attributed to external barriers but rather more so to inherent characteristics of SBI. To test our assumption, we conducted a vignette study assessing the GPs’ readiness to implement SBI in comparison to a pharmacological intervention also designed for the treatment of excessive drinkers in relation to standard or above-standard financial reimbursement. According to our hypothesis GPs should be less ready to implement SBI regardless of financial reimbursement. Methods A convenience sample of GPs was recruited to answer the questionnaire. To assess the GPs’ implementation readiness a 4-item 6-point Likert scale was developed and pretested. Results One hundred forty GPs completed the questionnaire. GPs were more ready to implement the pharmacological intervention than SBI, F(1,132) = 27.58, p > .001 (main effect). We found no effect for financial reimbursement, F(1,132) = 3.60, ns, and no interaction effect, F(1,132) = 2.20, ns. Conclusions Further research should investigate more thoroughly the crucial characteristics of SBI to initiate a modification process finally leading to more effective primary care dependency prevention.
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Affiliation(s)
- Thomas Fankhaenel
- University of Halle-Wittenberg, Halle, Germany. .,SRH University of Applied Health Sciences, Gera, Germany.
| | - Katrin Schulz
- SRH University of Applied Health Sciences, Gera, Germany
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Mauro M, Rotundo G, Giancotti M. Effect of financial incentives on breast, cervical and colorectal cancer screening delivery rates: Results from a systematic literature review. Health Policy 2019; 123:1210-1220. [PMID: 31587819 DOI: 10.1016/j.healthpol.2019.09.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 09/18/2019] [Accepted: 09/20/2019] [Indexed: 01/23/2023]
Abstract
Preventive care, such as screening, is important for reducing the risk of cancer, a leading cause of death worldwide. Indeed, some type of cancers are detected through screening programs, which in most countries run for colorectal, breast, and cervical cancers. In this context, general practitioners play a key role in increasing the participation rate in cancer screening programs. To improve cancer screening delivery rates, performance incentives have increasingly been implemented in primary care by healthcare payers and organizations in different countries. The effects of these tools are still not clear. We conducted a systematic literature review in order to answer the following research question: What is the evidence in the literature for the effects of financial incentives on the delivery rates of breast, cervical and colorectal cancer screening in general practice? We performed a literature search in Web of Science, PubMed, Cochrane Library and Google Scholar, according to the PRISMA guidelines. 18 studies were selected, classified and discussed according to the health preventive services investigated. Most of studies showed partial or no effects of financial incentives on breast and cervical cancer screening delivery rates. Few positive or partial effects were found regarding colorectal cancer screening. Ongoing monitoring of incentive programs is critical to determining the effectiveness of financial incentives and their effects on the improvement of cancer screening delivery rates.
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Affiliation(s)
- Marianna Mauro
- Department of Clinical and Experimental Medicine, Magna Graecia University, Catanzaro, Italy.
| | - Giorgia Rotundo
- Department of Legal, Historical, Economic and Social Sciences, Magna Graecia University, Catanzaro, Italy.
| | - Monica Giancotti
- Department of Clinical and Experimental Medicine, Magna Graecia University, Viale Europa, Catanzaro, Italy.
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10
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Details matter: Physician responses to multiple payments for the same activity. Soc Sci Med 2019; 235:112343. [DOI: 10.1016/j.socscimed.2019.05.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 05/25/2019] [Accepted: 05/29/2019] [Indexed: 11/17/2022]
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Abstract
Abstract
Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.
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Sicsic J, Franc C. [General practitioners’ preferences towards incentive measures linked with cancer screening]. SANTE PUBLIQUE (VANDOEUVRE-LES-NANCY, FRANCE) 2019; S2:33-41. [PMID: 32372577 DOI: 10.3917/spub.197.0033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
INTRODUCTION General practitioners (GPs) play a key role in the delivery of preventive and screening services for breast, cervical, and colorectal cancers. Yet, their current provision of screening services remains low and varies considerably across screening contexts and GPs. This study investigates the determinants of GPs' involvement in cancer screening activities using discrete choice experiment (DCE) methodology. METHODS A representative sample of 402 GPs was recruited in France between March and April 2014. The participants completed 12 choice tasks designed to elicit their preferences for 5 cancer screening attributes aimed at increasing their supply of cancer screening services. RESULTS GPs are sensitive to both financial and non-financial incentives, such as a compensated training and systematic transmission of information about screened patients, aimed to facilitate communication between doctors and patients. There is also evidence that the preferences differ across screening contexts: GPs appear to be relatively more sensitive to financial incentives for being involved in colorectal cancer screening, whereas they have higher preference for non-financial incentives in breast and cervical cancers. CONCLUSION Our study provides new findings for policymakers interested in prioritizing levers to increase the supply of cancer screening services in general practice.
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Strumann C, Flägel K, Emcke T, Steinhäuser J. Procedures performed by general practitioners and general internal medicine physicians - a comparison based on routine data from Northern Germany. BMC FAMILY PRACTICE 2018; 19:189. [PMID: 30509221 PMCID: PMC6276264 DOI: 10.1186/s12875-018-0878-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/28/2018] [Accepted: 11/19/2018] [Indexed: 11/21/2022]
Abstract
Background In response to a rising shortage of general practitioners (GPs), physicians in general internal medicine (GIM) have become part of the German primary care physician workforce. Previous studies have shown substantial differences in practice patterns between both specialties. The aim of this study was to analyse and compare the application of procedures by German GPs and GIM physicians based on routine data. Methods The Association of Statutory Health Insurance Physicians in the federal state Schleswig-Holstein (Northern Germany) provided invoicing data of the first quarters of 2013 and 2015. Differences between GPs and GIM physicians in the implementation rate of 46 selected primary care procedures were examined by means of the Pearson χ2-test. The selection of procedures was based on international and own preliminary studies on primary care procedures. Results In the first quarter of 2013/2015 respectively, 1228/1227 GPs and 447/484 GIM physicians provided services in Schleswig-Holstein. Significant differences were found for 20 of the 46 procedures. GPs had higher application rates of procedures concerning health screening (e.g. adolescent health examination, well-child visits) and minor surgery. GIM physicians more often applied technology-oriented procedures, such as ultrasound scans, electrocardiograms (ECG), and 24-h ambulatory blood pressure measurements. The treatment patterns of both specialities did not vary much during the study period. Cardiac stress testing was the only significantly increased GP procedure in that time. Conclusions Our results suggest substantial differences in the application of procedures between GPs and GIM physicians with potential consequences for the overall primary healthcare provision. The findings could foster a discussion about training needs for procedures in primary care to ensure its comprehensiveness. The results reflect scope for changes in vocational training in the future for an effective and efficient re-allocation of primary healthcare.
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Affiliation(s)
- C Strumann
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany.
| | - K Flägel
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany
| | - T Emcke
- Association of Statutory Health Insurance Physicians of the Federal State of Schleswig-Holstein, Bismarckallee 1-6, 23795, Bad Segeberg, Germany
| | - J Steinhäuser
- Institute of Family Medicine, University Hospital Schleswig-Holstein, Campus Luebeck, Ratzeburger Allee 160, 23538, Luebeck, Germany
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Vermeulen L, Schäfer W, Pavlic DR, Groenewegen P. Community orientation of general practitioners in 34 countries. Health Policy 2018; 122:1070-1077. [PMID: 30041912 DOI: 10.1016/j.healthpol.2018.06.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 06/13/2018] [Accepted: 06/26/2018] [Indexed: 11/26/2022]
Abstract
General practitioners (GPs) are frontline health workers. They should be sensitive to the health needs of the community in addition to caring for patients that visit their practice. Due to changes in demography, epidemiology, ecology and healthcare policy, a community orientation becomes more important. Our research question is: to what extent does community orientation of GPs vary between countries and GPs and how can this variation be explained? We use cross-sectional survey data from the QUALICOPC study, conducted among over 7000 GPs in 34 countries. Community orientation was measured through a scale constructed from three survey questions on whether GPs would take action when confronted with: repeated accidents in an industrial setting, frequent respiratory problems in patients living near a certain industry, and repeated cases of food poisoning in the local community. Independent variables are at healthcare system level and GP or practice level. Data were analysed using linear multilevel regression analysis. Community orientation varies between GPs and countries. Community orientation is more frequent in healthcare systems with a list system, among self-employed GPs, those using medical records to make overviews, and those more active in prevention and multidisciplinary cooperation. GPs in rural areas and areas with more people from ethnic minorities are more community oriented. Based on the variation between countries and GPs, we would like to raise awareness and underline the importance of multidisciplinary cooperation.
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Affiliation(s)
- Lisa Vermeulen
- Netherlands Institute for Health Services Research, Otterstraat 118, 3513 CR, Utrecht, The Netherlands; Yong B.V., Jan Steenlaan 127, 6717 TB, Ede, The Netherlands.
| | - Willemijn Schäfer
- Netherlands Institute for Health Services Research, Otterstraat 118, 3513 CR, Utrecht, The Netherlands; Northwestern University, Feinberg School of Medicine, Department of Social Medical Sciences, 625 N. Michigan Ave, 27th floor, Chicago, IL, 60611, USA; NorthShore University Health System, Department of Family Medicine, Research Institute, 1001 University Place, Evanston, IL, 60201, USA.
| | - Danica Rotar Pavlic
- Department of Family Medicine, University of Ljubljana, Poljanski nasip 58, 1000, Ljubljana, Slovenia
| | - Peter Groenewegen
- Netherlands Institute for Health Services Research, Otterstraat 118, 3513 CR, Utrecht, The Netherlands; Utrecht University, The Netherlands.
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Ellegård LM, Dietrichson J, Anell A. Can pay-for-performance to primary care providers stimulate appropriate use of antibiotics? HEALTH ECONOMICS 2018; 27:e39-e54. [PMID: 28685902 PMCID: PMC5836891 DOI: 10.1002/hec.3535] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 03/27/2017] [Accepted: 05/15/2017] [Indexed: 05/05/2023]
Abstract
Antibiotic resistance is a major threat to public health worldwide. As the healthcare sector's use of antibiotics is an important contributor to the development of resistance, it is crucial that physicians only prescribe antibiotics when needed and that they choose narrow-spectrum antibiotics, which act on fewer bacteria types, when possible. Inappropriate use of antibiotics is nonetheless widespread, not least for respiratory tract infections (RTI), a common reason for antibiotics prescriptions. We examine if pay-for-performance (P4P) presents a way to influence primary care physicians' choice of antibiotics. During 2006-2013, 8 Swedish healthcare authorities adopted P4P to make physicians select narrow-spectrum antibiotics more often in the treatment of children with RTI. Exploiting register data on all purchases of RTI antibiotics in a difference-in-differences analysis, we find that P4P significantly increased the share of narrow-spectrum antibiotics. There are no signs that physicians gamed the system by issuing more prescriptions overall.
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Affiliation(s)
| | - Jens Dietrichson
- SFIThe Danish National Centre for Social ResearchCopenhagenDenmark
| | - Anders Anell
- Department of Business AdministrationLund UniversityLundSweden
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Rudoler D, de Oliveira C, Cheng J, Kurdyak P. Payment incentives for community-based psychiatric care in Ontario, Canada. CMAJ 2017; 189:E1509-E1516. [PMID: 29229712 DOI: 10.1503/cmaj.160816] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND In September 2011, the government of Ontario implemented payment incentives to encourage the delivery of community-based psychiatric care to patients after discharge from a psychiatric hospital admission and to those with a recent suicide attempt. We evaluated whether these incentives affected supply of psychiatric services and access to care. METHODS We used administrative data to capture monthly observations for all psychiatrists who practised in Ontario between September 2009 and August 2014. We conducted interrupted time-series analyses of psychiatrist-level and patient-level data to evaluate whether the incentives affected the quantity of eligible outpatient services delivered and the likelihood of receiving follow-up care. RESULTS Among 1921 psychiatrists evaluated, implementation of the incentive payments was not associated with increased provision of follow-up visits after discharge from a psychiatric hospital admission (mean change in visits per month per psychiatrist 0.0099, 95% confidence interval [CI] -0.0989 to 0.1206; change in trend 0.0032, 95% CI -0.0035 to 0.0095) or after a suicide attempt (mean change -0.0910, 95% CI -0.1885 to 0.0026; change in trend 0.0102, 95% CI 0.0045 to 0.0159). There was also no change in the probability that patients received follow-up care after discharge (change in level -0.0079, 95% CI -0.0223 to 0.0061; change in trend 0.0007, 95% CI -0.0003 to 0.0016) or after a suicide attempt (change in level 0.0074, 95% CI -0.0094 to 0.0366; change in trend 0.0006, 95% CI -0.0007 to 0.0022). INTERPRETATION Our results suggest that implementation of the incentives did not increase access to follow-up care for patients after discharge from a psychiatric hospital admission or after a suicide attempt, and the incentives had no effect on supply of psychiatric services. Further research to guide design and implementation of more effective incentives is warranted.
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Affiliation(s)
- David Rudoler
- Institute for Mental Health Policy Research (Rudoler, de Oliveira, Cheng, Kurdyak), Centre for Addiction and Mental Health; Mental Health and Addictions Research Program (Rudoler, de Oliveira, Cheng, Kurdyak), Institute for Clinical Evaluative Sciences; Department of Psychiatry, Faculty of Medicine (Kurdyak) and Institute of Health Policy, Management and Evaluation (Rudoler, de Oliveira, Cheng), University of Toronto, Toronto, Ont.
| | - Claire de Oliveira
- Institute for Mental Health Policy Research (Rudoler, de Oliveira, Cheng, Kurdyak), Centre for Addiction and Mental Health; Mental Health and Addictions Research Program (Rudoler, de Oliveira, Cheng, Kurdyak), Institute for Clinical Evaluative Sciences; Department of Psychiatry, Faculty of Medicine (Kurdyak) and Institute of Health Policy, Management and Evaluation (Rudoler, de Oliveira, Cheng), University of Toronto, Toronto, Ont
| | - Joyce Cheng
- Institute for Mental Health Policy Research (Rudoler, de Oliveira, Cheng, Kurdyak), Centre for Addiction and Mental Health; Mental Health and Addictions Research Program (Rudoler, de Oliveira, Cheng, Kurdyak), Institute for Clinical Evaluative Sciences; Department of Psychiatry, Faculty of Medicine (Kurdyak) and Institute of Health Policy, Management and Evaluation (Rudoler, de Oliveira, Cheng), University of Toronto, Toronto, Ont
| | - Paul Kurdyak
- Institute for Mental Health Policy Research (Rudoler, de Oliveira, Cheng, Kurdyak), Centre for Addiction and Mental Health; Mental Health and Addictions Research Program (Rudoler, de Oliveira, Cheng, Kurdyak), Institute for Clinical Evaluative Sciences; Department of Psychiatry, Faculty of Medicine (Kurdyak) and Institute of Health Policy, Management and Evaluation (Rudoler, de Oliveira, Cheng), University of Toronto, Toronto, Ont
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Wiysonge CS, Paulsen E, Lewin S, Ciapponi A, Herrera CA, Opiyo N, Pantoja T, Rada G, Oxman AD. Financial arrangements for health systems in low-income countries: an overview of systematic reviews. Cochrane Database Syst Rev 2017; 9:CD011084. [PMID: 28891235 PMCID: PMC5618470 DOI: 10.1002/14651858.cd011084.pub2] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND One target of the Sustainable Development Goals is to achieve "universal health coverage, including financial risk protection, access to quality essential health-care services and access to safe, effective, quality and affordable essential medicines and vaccines for all". A fundamental concern of governments in striving for this goal is how to finance such a health system. This concern is very relevant for low-income countries. OBJECTIVES To provide an overview of the evidence from up-to-date systematic reviews about the effects of financial arrangements for health systems in low-income countries. Secondary objectives include identifying needs and priorities for future evaluations and systematic reviews on financial arrangements, and informing refinements in the framework for financial arrangements presented in the overview. METHODS We searched Health Systems Evidence in November 2010 and PDQ-Evidence up to 17 December 2016 for systematic reviews. We did not apply any date, language, or publication status limitations in the searches. We included well-conducted systematic reviews of studies that assessed the effects of financial arrangements on patient outcomes (health and health behaviours), the quality or utilisation of healthcare services, resource use, healthcare provider outcomes (such as sick leave), or social outcomes (such as poverty, employment, or financial burden of patients, e.g. out-of-pocket payment, catastrophic disease expenditure) and that were published after April 2005. We excluded reviews with limitations important enough to compromise the reliability of the findings. Two overview authors independently screened reviews, extracted data, and assessed the certainty of evidence using GRADE. We prepared SUPPORT Summaries for eligible reviews, including key messages, 'Summary of findings' tables (using GRADE to assess the certainty of the evidence), and assessments of the relevance of findings to low-income countries. MAIN RESULTS We identified 7272 reviews and included 15 in this overview, on: collection of funds (2 reviews), insurance schemes (1 review), purchasing of services (1 review), recipient incentives (6 reviews), and provider incentives (5 reviews). The reviews were published between 2008 and 2015; focused on 13 subcategories; and reported results from 276 studies: 115 (42%) randomised trials, 11 (4%) non-randomised trials, 23 (8%) controlled before-after studies, 51 (19%) interrupted time series, 9 (3%) repeated measures, and 67 (24%) other non-randomised studies. Forty-three per cent (119/276) of the studies included in the reviews took place in low- and middle-income countries. Collection of funds: the effects of changes in user fees on utilisation and equity are uncertain (very low-certainty evidence). It is also uncertain whether aid delivered under the Paris Principles (ownership, alignment, harmonisation, managing for results, and mutual accountability) improves health outcomes compared to aid delivered without conforming to those principles (very low-certainty evidence). Insurance schemes: community-based health insurance may increase service utilisation (low-certainty evidence), but the effects on health outcomes are uncertain (very low-certainty evidence). It is uncertain whether social health insurance improves utilisation of health services or health outcomes (very low-certainty evidence). Purchasing of services: it is uncertain whether increasing salaries of public sector healthcare workers improves the quantity or quality of their work (very low-certainty evidence). Recipient incentives: recipient incentives may improve adherence to long-term treatments (low-certainty evidence), but it is uncertain whether they improve patient outcomes. One-time recipient incentives probably improve patient return for start or continuation of treatment (moderate-certainty evidence) and may improve return for tuberculosis test readings (low-certainty evidence). However, incentives may not improve completion of tuberculosis prophylaxis, and it is uncertain whether they improve completion of treatment for active tuberculosis. Conditional cash transfer programmes probably lead to an increase in service utilisation (moderate-certainty evidence), but their effects on health outcomes are uncertain. Vouchers may improve health service utilisation (low-certainty evidence), but the effects on health outcomes are uncertain (very low-certainty evidence). Introducing a restrictive cap may decrease use of medicines for symptomatic conditions and overall use of medicines, may decrease insurers' expenditures on medicines (low-certainty evidence), and has uncertain effects on emergency department use, hospitalisations, and use of outpatient care (very low-certainty evidence). Reference pricing, maximum pricing, and index pricing for drugs have mixed effects on drug expenditures by patients and insurers as well as the use of brand and generic drugs. Provider incentives: the effects of provider incentives are uncertain (very low-certainty evidence), including: the effects of provider incentives on the quality of care provided by primary care physicians or outpatient referrals from primary to secondary care, incentives for recruiting and retaining health professionals to serve in remote areas, and the effects of pay-for-performance on provider performance, the utilisation of services, patient outcomes, or resource use in low-income countries. AUTHORS' CONCLUSIONS Research based on sound systematic review methods has evaluated numerous financial arrangements relevant to low-income countries, targeting different levels of the health systems and assessing diverse outcomes. However, included reviews rarely reported social outcomes, resource use, equity impacts, or undesirable effects. We also identified gaps in primary research because of uncertainty about applicability of the evidence to low-income countries. Financial arrangements for which the effects are uncertain include external funding (aid), caps and co-payments, pay-for-performance, and provider incentives. Further studies evaluating the effects of these arrangements are needed in low-income countries. Systematic reviews should include all outcomes that are relevant to decision-makers and to people affected by changes in financial arrangements.
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Affiliation(s)
- Charles S Wiysonge
- South African Medical Research CouncilCochrane South AfricaFrancie van Zijl Drive, Parow ValleyCape TownWestern CapeSouth Africa7505
- Stellenbosch UniversityCentre for Evidence‐based Health Care, Faculty of Medicine and Health SciencesCape TownSouth Africa
| | - Elizabeth Paulsen
- Norwegian Institute of Public HealthP.O. Box 4404NydalenOsloNorwayN‐0403
| | - Simon Lewin
- Norwegian Institute of Public HealthP.O. Box 4404NydalenOsloNorwayN‐0403
- South African Medical Research CouncilHealth Systems Research UnitPO Box 19070TygerbergSouth Africa7505
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresCapital FederalArgentinaC1414CPV
| | - Cristian A Herrera
- Pontificia Universidad Católica de ChileDepartment of Public Health, School of MedicineMarcoleta 434SantiagoChile
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
| | - Newton Opiyo
- CochraneCochrane Editorial UnitSt Albans House, 57‐59 HaymarketLondonUKSW1Y 4QX
| | - Tomas Pantoja
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Family Medicine, Faculty of MedicineCentro Medico San Joaquin, Vicuña Mackenna 4686MaculSantiagoChile
| | - Gabriel Rada
- Pontificia Universidad Católica de ChileEvidence Based Health Care ProgramSantiagoChile
- Pontificia Universidad Católica de ChileDepartment of Internal Medicine and Evidence‐Based Healthcare Program, Faculty of MedicineLira 44, Decanato Primer pisoSantiagoChile
| | - Andrew D Oxman
- Norwegian Institute of Public HealthP.O. Box 4404NydalenOsloNorwayN‐0403
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Sicsic J, Franc C. Impact assessment of a pay-for-performance program on breast cancer screening in France using micro data. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2017; 18:609-621. [PMID: 27329654 DOI: 10.1007/s10198-016-0813-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/14/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND A voluntary-based pay-for-performance (P4P) program (the CAPI) aimed at general practitioners (GPs) was implemented in France in 2009. The program targeted prevention practices, including breast cancer screening, by offering a maximal amount of €245 for achieving a target screening rate among eligible women enrolled with the GP. OBJECTIVE Our objective was to evaluate the impact of the French P4P program (CAPI) on the early detection of breast cancer among women between 50 and 74 years old. METHODS Based on an administrative database of 50,752 women aged 50-74 years followed between 2007 and 2011, we estimated a difference-in-difference model of breast cancer screening uptake as a function of visit to a CAPI signatory referral GP, while controlling for both supply-side and demand-side determinants (e.g., sociodemographics, health and healthcare use). RESULTS Breast cancer screening rates have not changed significantly since the P4P program implementation. Overall, visiting a CAPI signatory referral GP at least once in the pre-CAPI period increased the probability of undergoing breast cancer screening by 1.38 % [95 % CI (0.41-2.35 %)], but the effect was not significantly different following the implementation of the contract. CONCLUSION The French P4P program had a nonsignificant impact on breast cancer screening uptake. This result may reflect the fact that the low-powered incentives implemented in France through the CAPI might not provide sufficient leverage to generate better practices, thus inviting regulators to seek additional tools beyond P4P in the field of prevention and screening.
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Affiliation(s)
- Jonathan Sicsic
- CESP, Univ. Paris-Sud, UVSQ, INSERM, Université Paris-Saclay, Hôpital Paul Brousse, 16 avenue Paul Vaillant-Couturier, 94807, Villejuif Cedex, France.
| | - Carine Franc
- CESP, Univ. Paris-Sud, UVSQ, INSERM, Université Paris-Saclay, Hôpital Paul Brousse, 16 avenue Paul Vaillant-Couturier, 94807, Villejuif Cedex, France
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Abstract
This paper provides an overview of brief intervention (BI) research to date and discusses future research needs as well as strategies for more widespread use of BI. Research has firmly established that significant reductions in drinking can be achieved by BI in a variety of health care settings. Despite convincing evidence, however, diffusion of BI in routine health care has been slow. Alcohol is a complex subject since it is often used moderately, without side-effects, and in a socially acceptable way. Although research on BI has accumulated rapidly during the last three decades, many important research challenges and development work remain before BI is widely implemented in routine health care.
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Affiliation(s)
- Per Nilsen
- Dep. of Social Medicine and Public Health Lindköping university, Sweden
| | - Eileen Kaner
- Inst. of Health & Society, Newcastle university, UK
| | - Thomas F. Babor
- Dep. of Community Medicine and Health Care University of Connecticut Health Center, Farmington, Connecticut, USA
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Bastian ND, Kang H, Nembhard HB, Bloschichak A, Griffin PM. The Impact of a Pay-for-Performance Program on Central Line-Associated Blood Stream Infections in Pennsylvania. Hosp Top 2017; 94:8-14. [PMID: 26980202 DOI: 10.1080/00185868.2015.1130542] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Healthcare associated infections have significantly contributed to the rising cost of hospital care in the United States. The implementation of pay-for-performance (P4P) programs has been one approach to improve quality at a reduced cost. We quantify the impact of Highmark's Quality Blue (QB) hospital P4P program on central line-associated blood stream infections (CLABSI) in Pennsylvania. The impact of years of participation in QB on CLABSI is also evaluated. Data from 149 Pennsylvania hospitals on CLABSI from 2008-2013 are used. Negative binomial regression and fixed effects panel regression are performed. Hospitals participating in QB have 0.727 times the CLABSI as those hospitals that do not participate. Hospitals participating for four or more years have on average 3.13 fewer CLABSI per year compared to those participating for less than four years. Highmark's P4P program has shown improved outcomes with regards to CLABSI, but further research is needed to determine if QB is cost effective.
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Affiliation(s)
- Nathaniel D Bastian
- a Center for Integrated Healthcare Delivery Systems , Department of Industrial and Manufacturing Engineering, Pennsylvania State University , University Park , Pennsylvania , USA
| | - Hyojung Kang
- b Department of Systems and Information Engineering , University of Virginia , Charlottesville , Virginia , USA
| | - Harriet B Nembhard
- a Center for Integrated Healthcare Delivery Systems , Department of Industrial and Manufacturing Engineering, Pennsylvania State University , University Park , Pennsylvania , USA
| | - Andrew Bloschichak
- c Medical Policy Development , Highmark Medical Services , Camp Hill , Pennsylvania , USA
| | - Paul M Griffin
- d Center for Health and Humanitarian Systems , School of Industrial and Systems Engineering , Georgia Institute of Technology , Atlanta , Georgia , USA
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Dean CA, Arnold LD, Hauptman PJ, Wang J, Elder K. Patient, Physician, and Practice Characteristics Associated with Cardiovascular Disease Preventive Care for Women. J Womens Health (Larchmt) 2017; 26:491-499. [PMID: 28437218 DOI: 10.1089/jwh.2015.5613] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of death for American women. Although CVD preventive care has the potential to reduce a significant number of these deaths, the degree to which healthcare providers deliver such care is unknown. The purpose of this study was to identify patient, physician, and practice characteristics that significantly influence the provision of CVD preventive care during ambulatory care visits for female patients. METHODS The National Ambulatory Medical Care Survey datasets from 2005 to 2010 were utilized. The study sample included female patients ≥20 years of age whose healthcare provider performed CVD preventive care and who had visits for a new health problem, a routine chronic problem, management of a chronic condition, and preventive care. Binary logistic regression models estimated the association of patient, physician, and practice characteristics and CVD preventive care; cholesterol testing, body mass index (BMI) screening, and tobacco education. RESULTS Of the 32,009 visits, 15.9% involved cholesterol testing, 50.3% involved BMI screening, and 3.20% involved tobacco education. Obstetricians/gynecologists were less likely to perform cholesterol testing (aOR: 0.39; 95% CI: 0.25-0.61) and tobacco education (aOR: 0.56; 95% CI: 0.32-0.98) than general/family physicians. CONCLUSION The delivery of CVD preventive care varied by healthcare provider type, with obstetricians/gynecologists having lower odds of providing two of the three services. The amount of time a physician spent with a patient was a significant predictor for the provision of all three services. These findings demonstrate the need to implement multifaceted approaches to address predicting characteristics of CVD preventive care.
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Affiliation(s)
- Caress A Dean
- 1 Master of Public Health Program, School of Health Sciences, Oakland University , Rochester, Michigan
| | - Lauren D Arnold
- 2 Department of Epidemiology, College for Public Health and Social Justice, Saint Louis University , St. Louis, Missouri
| | - Paul J Hauptman
- 3 Division of Cardiology, Saint Louis University School of Medicine, Saint Louis University Hospital , St. Louis, Missouri
| | - Jing Wang
- 4 Department of Biostatistics, College for Public Health and Social Justice, Saint Louis University , St. Louis, Missouri
| | - Keith Elder
- 5 School of Public Health, Samford University , Birmingham, Alabama
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Diop M, Fiset-Laniel J, Provost S, Tousignant P, Borgès Da Silva R, Ouimet MJ, Latimer E, Strumpf E. Does enrollment in multidisciplinary team-based primary care practice improve adherence to guideline-recommended processes of care? Quebec's Family Medicine Groups, 2002-2010. Health Policy 2017; 121:378-388. [PMID: 28233598 DOI: 10.1016/j.healthpol.2017.02.001] [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: 08/15/2016] [Revised: 11/23/2016] [Accepted: 02/01/2017] [Indexed: 01/25/2023]
Abstract
BACKGROUND We investigated whether multidisciplinary team-based primary care practice improves adherence to process of care guidelines, in the absence of financial incentives related to pay-for-performance. METHODS We conducted a natural experiment including 135,119 patients, enrolled with a general practitioner (GP) in a multidisciplinary team Family Medicine Group (FMG) or non-FMG practice, using longitudinal data from Quebec's universal insurer over the relevant time period (2000-2010). All study subjects had diabetes, chronic obstructive pulmonary disease, or heart failure and were followed over a 7-year period, 2 years prior to enrollment and 5 years after. We constructed indicators on adherence to disease-specific guidelines and composite indicators across conditions. We evaluated the effect of FMGs using propensity score methods and Difference-in-Differences (DD) models. RESULTS Rates of adherence to chronic disease guidelines increased for both FMG and non-FMG patients after enrollment, but not differentially so. Adherence to prescription-related guidelines improved less for FMG patients (DD [95% CI]=-2.83% [-4.08%, -1.58%]). We found no evidence of an FMG effect on adherence to consultation-related guidelines, (DD [95% CI]=-0.24% [-2.24%; 1.75%]). CONCLUSIONS We found no evidence that FMGs increased adherence to the guidelines we evaluated. Future research is needed to assess why this reform did not improve performance on these quality-of-care indicators.
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Affiliation(s)
- Mamadou Diop
- McGill University, Department of Epidemiology, Biostatistics and Occupational Health, 1020 Pine Ave. West, Montreal, QC H3A 1A2 Canada; Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada
| | - Julie Fiset-Laniel
- McGill University, Department of Epidemiology, Biostatistics and Occupational Health, 1020 Pine Ave. West, Montreal, QC H3A 1A2 Canada; Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada
| | - Sylvie Provost
- Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada; Institut de recherche en santé publique de l'Université de Montréal, Pavillon 7101 avenue du Parc, C.P. 6128, Succ. Centre-Ville, Montreal, QC H3C 3J7 Canada
| | - Pierre Tousignant
- McGill University, Department of Epidemiology, Biostatistics and Occupational Health, 1020 Pine Ave. West, Montreal, QC H3A 1A2 Canada; Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada
| | - Roxane Borgès Da Silva
- Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada; Université de Montréal, Faculté des sciences infirmières, Marguerite-d'Youville C.P 6128, succursale Centre-ville, Montréal, QC H3C 3J7 Canada
| | - Marie-Jo Ouimet
- Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada
| | - Eric Latimer
- McGill University, Department of Epidemiology, Biostatistics and Occupational Health, 1020 Pine Ave. West, Montreal, QC H3A 1A2 Canada; Douglas Mental Health University Institute, Perry Pavilion Room E-3114, 6875 boulevard LaSalle, Montreal, QC H4H 1R3 Canada
| | - Erin Strumpf
- McGill University, Department of Epidemiology, Biostatistics and Occupational Health, 1020 Pine Ave. West, Montreal, QC H3A 1A2 Canada; Direction de santé publique du CIUSS du Centre-Sud-de-l'Île-de-Montréal, 1301 Sherbrooke St. East, Montreal, QC H2L 1M3 Canada; Institut de recherche en santé publique de l'Université de Montréal, Pavillon 7101 avenue du Parc, C.P. 6128, Succ. Centre-Ville, Montreal, QC H3C 3J7 Canada; McGill University, Department of Economics, 855 Sherbrooke St. West, Leacock 418, Montreal, QC H3A 2T7 Canada.
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The influence of welfare systems on pay-for-performance programs for general practitioners: A critical review. Soc Sci Med 2017; 178:157-166. [PMID: 28226301 DOI: 10.1016/j.socscimed.2017.02.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 02/10/2017] [Accepted: 02/12/2017] [Indexed: 12/11/2022]
Abstract
While pay-for-performance (P4P) programs are increasingly common tools used to foster quality and efficiency in primary care, the evidence concerning their effectiveness is at best mixed. In this article, we explore the influence of welfare systems on four P4P-related dimensions: the level of healthcare funders' commitment to P4Ps (by funding and length of program operation), program design (specifically target-based vs. participation-based program), physicians' acceptance of the program and program effects. Using Esping-Andersen's typology, we examine P4P for general practitioners (GPs) in thirteen European and North American countries and find that welfare systems contribute to explain variations in P4P experiences. Overall, liberal systems exhibited the most enthusiastic adoption of P4P, with significant physician acceptance, generous incentives and positive but modest program effects. Social democratic countries showed minimal interest in P4P for GPs, with the exception of Sweden. Although corporatist systems adopted performance pay, these countries experienced mixed results, with strong physician opposition. In response to this opposition, health care funders tended to favour participation-based over target-based P4P. We demonstrate how the interaction of decommodification and social stratification in each welfare regime influences these countries' experiences with P4P for GPs, directly for funders' commitment, program design and physicians' acceptance, and indirectly for program effects, hence providing a framework for analyzing P4P in other contexts or care settings.
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Constantinou P, Sicsic J, Franc C. Effect of pay-for-performance on cervical cancer screening participation in France. INTERNATIONAL JOURNAL OF HEALTH ECONOMICS AND MANAGEMENT 2016; 17:10.1007/s10754-016-9207-3. [PMID: 28005224 DOI: 10.1007/s10754-016-9207-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 12/04/2016] [Indexed: 06/06/2023]
Abstract
Pay-for-performance (P4P) has been increasingly used across different healthcare settings to incentivize the provision of targeted services. In this study, we investigated the effect of a nationwide P4P scheme for general practitioners implemented in 2012 in France, on cervical cancer screening practices. Using data from a nationally representative permanent sample of health insurance beneficiaries, we analyzed smear test use of eligible women for the years 2006-2014. Our longitudinal sample was an unbalanced panel comprising 180,167 women eligible from 1 to 9 years each. We took into account that during our study period some women were exposed to another incentive for screening participation: the implementation in 2010 of organized screening (OS) in a limited number of areas. To evaluate the effect of P4P, we defined three different measures of smear utilization. For each measure, we specified binary panel-data models to estimate annual probabilities and to compare each estimate to the 2011 baseline level. To explore the combined effect of P4P and OS in areas exposed to both incentives, we computed interaction terms between year dummies and area of residence. We found that P4P had a modest positive effect on recommended screening participation. This effect is likely to be transient as annual smear use, both for the whole sample and among women overdue for screening, increased only in 2013 and decreased again in 2014. The combined effect of P4P and OS on screening participation was not cumulative during the first years of coexistence.
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Affiliation(s)
- Panayotis Constantinou
- INSERM, Centre for Research in Epidemiology and Population Health, Université Paris-Saclay, Université Paris-Sud, UVSQ, 16, avenue Paul Vaillant Couturier, 94807, Villejuif Cedex, France.
| | - Jonathan Sicsic
- INSERM, Centre for Research in Epidemiology and Population Health, Université Paris-Saclay, Université Paris-Sud, UVSQ, 16, avenue Paul Vaillant Couturier, 94807, Villejuif Cedex, France
| | - Carine Franc
- INSERM, Centre for Research in Epidemiology and Population Health, Université Paris-Saclay, Université Paris-Sud, UVSQ, 16, avenue Paul Vaillant Couturier, 94807, Villejuif Cedex, France
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Silverman K, Jarvis BP, Jessel J, Lopez AA. Incentives and Motivation. TRANSLATIONAL ISSUES IN PSYCHOLOGICAL SCIENCE 2016; 2:97-100. [PMID: 27917395 DOI: 10.1037/tps0000073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Kenneth Silverman
- Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | - Brantley P Jarvis
- Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine
| | | | - Alexa A Lopez
- Department of Psychology, Virginia Commonwealth University
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Ammi M, Peyron C. Heterogeneity in general practitioners' preferences for quality improvement programs: a choice experiment and policy simulation in France. HEALTH ECONOMICS REVIEW 2016; 6:44. [PMID: 27637834 PMCID: PMC5025412 DOI: 10.1186/s13561-016-0121-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 09/08/2016] [Indexed: 05/27/2023]
Abstract
Despite increasing popularity, quality improvement programs (QIP) have had modest and variable impacts on enhancing the quality of physician practice. We investigate the heterogeneity of physicians' preferences as a potential explanation of these mixed results in France, where the national voluntary QIP - the CAPI - has been cancelled due to its unpopularity. We rely on a discrete choice experiment to elicit heterogeneity in physicians' preferences for the financial and non-financial components of QIP. Using mixed and latent class logit models, results show that the two models should be used in concert to shed light on different aspects of the heterogeneity in preferences. In particular, the mixed logit demonstrates that heterogeneity in preferences is concentrated on the pay-for-performance component of the QIP, while the latent class model shows that physicians can be grouped in four homogeneous groups with specific preference patterns. Using policy simulation, we compare the French CAPI with other possible QIPs, and show that the majority of the physician subgroups modelled dislike the CAPI, while favouring a QIP using only non-financial interventions. We underline the importance of modelling preference heterogeneity in designing and implementing QIPs.
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Affiliation(s)
- Mehdi Ammi
- School of Public Policy and Administration, Carleton University, River Building, 1125 Colonel By Drive, Ottawa, ON, K1S 5B6, Canada.
| | - Christine Peyron
- Laboratoire d'Économie de Dijon, Université de Bourgogne, CNRS UMR 6307, Inserm U 1200, Dijon, France
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Sicsic J, Krucien N, Franc C. What are GPs' preferences for financial and non-financial incentives in cancer screening? Evidence for breast, cervical, and colorectal cancers. Soc Sci Med 2016; 167:116-27. [DOI: 10.1016/j.socscimed.2016.08.050] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Revised: 08/26/2016] [Accepted: 08/27/2016] [Indexed: 11/25/2022]
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Gong CL, Hay JW, Meeker D, Doctor JN. Prescriber preferences for behavioural economics interventions to improve treatment of acute respiratory infections: a discrete choice experiment. BMJ Open 2016; 6:e012739. [PMID: 27660322 PMCID: PMC5051402 DOI: 10.1136/bmjopen-2016-012739] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE To elicit prescribers' preferences for behavioural economics interventions designed to reduce inappropriate antibiotic prescribing, and compare these to actual behaviour. DESIGN Discrete choice experiment (DCE). SETTING 47 primary care centres in Boston and Los Angeles. PARTICIPANTS 234 primary care providers, with an average 20 years of practice. MAIN OUTCOMES AND MEASURES Results of a behavioural economic intervention trial were compared to prescribers' stated preferences for the same interventions relative to monetary and time rewards for improved prescribing outcomes. In the randomised controlled trial (RCT) component, the 3 computerised prescription order entry-triggered interventions studied included: Suggested Alternatives (SA), an alert that populated non-antibiotic treatment options if an inappropriate antibiotic was prescribed; Accountable Justifications (JA), which prompted the prescriber to enter a justification for an inappropriately prescribed antibiotic that would then be documented in the patient's chart; and Peer Comparison (PC), an email periodically sent to each prescriber comparing his/her antibiotic prescribing rate with those who had the lowest rates of inappropriate antibiotic prescribing. A DCE study component was administered to determine whether prescribers felt SA, JA, PC, pay-for-performance or additional clinic time would most effectively reduce their inappropriate antibiotic prescribing. Willingness-to-pay (WTP) was calculated for each intervention. RESULTS In the RCT, PC and JA were found to be the most effective interventions to reduce inappropriate antibiotic prescribing, whereas SA was not significantly different from controls. In the DCE however, regardless of treatment intervention received during the RCT, prescribers overwhelmingly preferred SA, followed by PC, then JA. WTP estimates indicated that each intervention would be significantly cheaper to implement than pay-for-performance incentives of $200/month. CONCLUSIONS Prescribing behaviour and stated preferences are not concordant, suggesting that relying on stated preferences alone to inform intervention design may eliminate effective interventions. TRIAL REGISTRATION NUMBER NCT01454947; Results.
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Affiliation(s)
- Cynthia L Gong
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California, USA
| | - Joel W Hay
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California, USA
| | - Daniella Meeker
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California, USA
- University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Jason N Doctor
- University of Southern California Leonard D. Schaeffer Center for Health Policy & Economics, Los Angeles, California, USA
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Lau R, Stevenson F, Ong BN, Dziedzic K, Treweek S, Eldridge S, Everitt H, Kennedy A, Qureshi N, Rogers A, Peacock R, Murray E. Achieving change in primary care--effectiveness of strategies for improving implementation of complex interventions: systematic review of reviews. BMJ Open 2015; 5:e009993. [PMID: 26700290 PMCID: PMC4691771 DOI: 10.1136/bmjopen-2015-009993] [Citation(s) in RCA: 135] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
OBJECTIVE To identify, summarise and synthesise available literature on the effectiveness of implementation strategies for optimising implementation of complex interventions in primary care. DESIGN Systematic review of reviews. DATA SOURCES MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from first publication until December 2013; the bibliographies of relevant articles were screened for additional reports. ELIGIBILITY CRITERIA FOR SELECTING STUDIES Eligible reviews had to (1) examine effectiveness of single or multifaceted implementation strategies, (2) measure health professional practice or process outcomes and (3) include studies from predominantly primary care in developed countries. Two reviewers independently screened titles/abstracts and full-text articles of potentially eligible reviews for inclusion. DATA SYNTHESIS Extracted data were synthesised using a narrative approach. RESULTS 91 reviews were included. The most commonly evaluated strategies were those targeted at the level of individual professionals, rather than those targeting organisations or context. These strategies (eg, audit and feedback, educational meetings, educational outreach, reminders) on their own demonstrated a small to modest improvement (2-9%) in professional practice or behaviour with considerable variability in the observed effects. The effects of multifaceted strategies targeted at professionals were mixed and not necessarily more effective than single strategies alone. There was relatively little review evidence on implementation strategies at the levels of organisation and wider context. Evidence on cost-effectiveness was limited and data on costs of different strategies were scarce and/or of low quality. CONCLUSIONS There is a substantial literature on implementation strategies aimed at changing professional practices or behaviour. It remains unclear which implementation strategies are more likely to be effective than others and under what conditions. Future research should focus on identifying and assessing the effectiveness of strategies targeted at the wider context and organisational levels and examining the costs and cost-effectiveness of implementation strategies. PROSPERO REGISTRATION NUMBER CRD42014009410.
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Affiliation(s)
- Rosa Lau
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
| | - Fiona Stevenson
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
| | - Bie Nio Ong
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, UK
| | - Krysia Dziedzic
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care Sciences and Health Sciences, Keele University, Keele, UK
| | - Shaun Treweek
- Health Services Research Unit, University of Aberdeen, Scotland, UK
| | - Sandra Eldridge
- Centre for Primary Care and Public Health, Queen Mary University of London, London, UK
| | - Hazel Everitt
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton,UK
| | - Anne Kennedy
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - Nadeem Qureshi
- Division of Primary Care, University of Nottingham, Derby, UK
| | - Anne Rogers
- Faculty of Health Sciences, NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | | | - Elizabeth Murray
- eHealth Unit, Department of Primary Care and Population Health, University College London, London, UK
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Layton TJ, Ryan AM. Higher Incentive Payments in Medicare Advantage's Pay-for-Performance Program Did Not Improve Quality But Did Increase Plan Offerings. Health Serv Res 2015; 50:1810-28. [PMID: 26549194 PMCID: PMC4693840 DOI: 10.1111/1475-6773.12409] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To evaluate the effects of the size of financial bonuses on quality of care and the number of plan offerings in the Medicare Advantage Quality Bonus Payment Demonstration. DATA SOURCES Publicly available data from CMS from 2009 to 2014 on Medicare Advantage plan quality ratings, the counties in the service area of each plan, and the benchmarks used to construct plan payments. STUDY DESIGN The Medicare Advantage Quality Bonus Payment Demonstration began in 2012. Under the Demonstration, all Medicare Advantage plans were eligible to receive bonus payments based on plan-level quality scores (star ratings). In some counties, plans were eligible to receive bonus payments that were twice as large as in other counties. We used this variation in incentives to evaluate the effects of bonus size on star ratings and the number of plan offerings in the Demonstration using a differences-in-differences identification strategy. We used matching to create a comparison group of counties that did not receive double bonuses but had similar levels of the preintervention outcomes. PRINCIPAL FINDINGS Results from the difference-in-differences analysis suggest that the receipt of double bonuses was not associated with an increase in star ratings. In the matched sample, the receipt of double bonuses was associated with a statistically insignificant increase of +0.034 (approximately 1 percent) in the average star rating (p > .10, 95 percent CI: -0.015, 0.083). In contrast, the receipt of double bonuses was associated with an increase in the number of plans offered. In the matched sample, the receipt of double bonuses was associated with an overall increase of +0.814 plans (approximately 5.8 percent) (p < .05, 95 percent CI: 0.078, 1.549). We estimate that the double bonuses increased payments by $3.43 billion over the first 3 years of the Demonstration. CONCLUSIONS At great expense to Medicare, double bonuses in the Medicare Advantage Quality Bonus Payment Demonstration were not associated with improved quality but were associated with more plan offerings.
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Affiliation(s)
| | - Andrew M. Ryan
- Department of Health Management and PolicySchool of Public HealthUniversity of MichiganAnn ArborMI
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Abstract
Pay-for-performance (P4P) schemes have become increasingly common in primary care, and this article reviews their impact. It is based primarily on existing systematic reviews. The evidence suggests that P4P schemes can change health professionals' behavior and improve recorded disease management of those clinical processes that are incentivized. P4P may narrow inequalities in performance comparing deprived with nondeprived areas. However, such schemes have unintended consequences. Whether P4P improves the patient experience, the outcomes of care or population health is less clear. These practical uncertainties mirror the ethical concerns of many clinicians that a reductionist approach to managing markers of chronic disease runs counter to the humanitarian values of family practice. The variation in P4P schemes between countries reflects different historical and organizational contexts. With so much uncertainty regarding the effects of P4P, policy makers are well advised to proceed carefully with the implementation of such schemes until and unless clearer evidence for their cost-benefit emerges.
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Affiliation(s)
- Stephen Gillam
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, UK
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Leaders’ experiences and perceptions implementing activity-based funding and pay-for-performance hospital funding models: A systematic review. Health Policy 2015; 119:1096-110. [DOI: 10.1016/j.healthpol.2015.05.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/10/2015] [Accepted: 05/04/2015] [Indexed: 12/19/2022]
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Greene J, Kurtzman ET, Hibbard JH, Overton V. Working under a clinic-level quality incentive: primary care clinicians' perceptions. Ann Fam Med 2015; 13:235-41. [PMID: 25964401 PMCID: PMC4427418 DOI: 10.1370/afm.1779] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND A key consideration in designing pay-for-performance programs is determining what entity the incentive should be awarded to-individual clinicians or to groups of clinicians working in teams. Some argue that team-level incentives, in which clinicians who are part of a team receive the same incentive based on the team's performance, are most effective; others argue for the efficacy of clinician-level incentives. This study examines primary care clinicians' perceptions of a team-based quality incentive awarded at the clinic level. METHODS This research was conducted with Fairview Health Services, where 40% of the primary care compensation model was based on clinic-level quality performance. We conducted 48 in-depth interviews to explore clinicians' perceptions of the clinic-level incentive, as well as an online survey of 150 clinicians (response rate 56%) to investigate which entity the clinicians would consider optimal to target for quality incentives. RESULTS Clinicians reported the strengths of the clinic-based quality incentive were quality improvement for the team and less patient "dumping," or shifting patients with poor outcomes to other clinicians. The weaknesses were clinicians' lack of control and colleagues riding the coattails of higher performers. There were mixed reports on the model's impact on team dynamics. Although clinicians reported greater interaction with colleagues, some described an increase in tension. Most clinicians surveyed (73%) believed that there should be a mix of clinic and individual-level incentives to maintain collaboration and recognize individual performance. CONCLUSION The study highlights the important advantages and disadvantages of using incentives based upon clinic-level performance. Future research should test whether hybrid incentives that mix group and individual incentives can maintain some of the best elements of each design while mitigating the negative impacts.
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Affiliation(s)
- Jessica Greene
- School of Nursing, The George Washington University, Washington, DC
| | - Ellen T Kurtzman
- School of Nursing, The George Washington University, Washington, DC
| | - Judith H Hibbard
- Department of Planning, Public Policy, and Management, Health Policy Research Group, University of Oregon
| | - Valerie Overton
- Vice President Quality and Innovation, Fairview Medical Group
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Salam RA, Lassi ZS, Das JK, Bhutta ZA. Evidence from district level inputs to improve quality of care for maternal and newborn health: interventions and findings. Reprod Health 2014; 11 Suppl 2:S3. [PMID: 25208460 PMCID: PMC4160920 DOI: 10.1186/1742-4755-11-s2-s3] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
District level healthcare serves as a nexus between community and district level facilities. Inputs at the district level can be broadly divided into governance and accountability mechanisms; leadership and supervision; financial platforms; and information systems. This paper aims to evaluate the effectivness of district level inputs for imporving maternal and newborn health. We considered all available systematic reviews published before May 2013 on the pre-defined district level interventions and included 47 systematic reviews. Evidence suggests that supervision positively influenced provider’s practice, knowledge and client/provider satisfaction. Involving local opinion leaders to promote evidence-based practice improved compliance to the desired practice. Audit and feedback mechanisms and tele-medicine were found to be associated with improved immunization rates and mammogram uptake. User-directed financial schemes including maternal vouchers, user fee exemption and community based health insurance showed significant impact on maternal health service utilization with voucher schemes showing the most significant positive impact across all range of outcomes including antenatal care, skilled birth attendant, institutional delivery, complicated delivery and postnatal care. We found insufficient evidence to support or refute the use of electronic health record systems and telemedicine technology to improve maternal and newborn health specific outcomes. There is dearth of evidence on the effectiveness of district level inputs to improve maternal newborn health outcomes. Future studies should evaluate the impact of supervision and monitoring; electronic health record and tele-communication interventions in low-middle-income countries.
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Halpern MT, Romaire MA, Haber SG, Tangka FK, Sabatino SA, Howard DH. Impact of state-specific Medicaid reimbursement and eligibility policies on receipt of cancer screening. Cancer 2014; 120:3016-24. [PMID: 25154930 DOI: 10.1002/cncr.28704] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 02/17/2014] [Accepted: 03/06/2014] [Indexed: 11/07/2022]
Abstract
BACKGROUND Although state Medicaid programs cover cancer screening, Medicaid beneficiaries are less likely to be screened for cancer and are more likely to present with tumors of an advanced stage than are those with other insurance. The current study was performed to determine whether state Medicaid eligibility and reimbursement policies affect the receipt of breast, cervical, and colon cancer screening among Medicaid beneficiaries. METHODS Cross-sectional regression analyses of 2007 Medicaid data from 46 states and the District of Columbia were performed to examine associations between state-specific Medicaid reimbursement/eligibility policies and receipt of cancer screening. The study sample included individuals aged 21 years to 64 years who were enrolled in fee-for-service Medicaid for at least 4 months. Subsamples eligible for each screening test were: Papanicolaou test among 2,136,511 patients, mammography among 792,470 patients, colonoscopy among 769,729 patients, and fecal occult blood test among 753,868 patients. State-specific Medicaid variables included median screening test reimbursement, income/financial asset eligibility requirements, physician copayments, and frequency of eligibility renewal. RESULTS Increases in screening test reimbursement demonstrated mixed associations (positive and negative) with the likelihood of receiving screening tests among Medicaid beneficiaries. In contrast, increased reimbursements for office visits were found to be positively associated with the odds of receiving all screening tests examined, including colonoscopy (odds ratio [OR], 1.07; 95% confidence interval [95% CI], 1.06-1.08), fecal occult blood test (OR, 1.09; 95% CI, 1.08-1.10), Papanicolaou test (OR, 1.02; 95% CI, 1.02-1.03), and mammography (OR, 1.02; 95% CI, 1.02-1.03). Effects of other state-specific Medicaid policies varied across the screening tests examined. CONCLUSIONS Increased reimbursement for office visits was consistently associated with an increased likelihood of being screened for cancer, and may be an important policy tool for increasing screening among this vulnerable population.
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Li J, Hurley J, DeCicca P, Buckley G. Physician response to pay-for-performance: evidence from a natural experiment. HEALTH ECONOMICS 2014; 23:962-78. [PMID: 23861240 DOI: 10.1002/hec.2971] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 06/07/2013] [Accepted: 06/14/2013] [Indexed: 05/13/2023]
Abstract
This study exploits a natural experiment in the province of Ontario, Canada, to identify the impact of pay-for-performance (P4P) incentives on the provision of targeted primary care services and whether physicians' responses differ by age, size of patient population, and baseline compliance level. We use administrative data that cover the full population of Ontario and nearly all the services provided by primary care physicians. We employ a difference-in-differences approach that controls for selection on observables and selection on unobservables that may cause estimation bias. We implement a set of robustness checks to control for confounding from other contemporaneous interventions of the primary care reform in Ontario. The results indicate that responses were modest and that physicians responded to the financial incentives for some services but not others. The results provide a cautionary message regarding the effectiveness of employing P4P to increase the quality of health care.
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MESH Headings
- Female
- Humans
- Male
- Middle Aged
- Models, Organizational
- Ontario
- Physicians, Primary Care/economics
- Physicians, Primary Care/psychology
- Physicians, Primary Care/trends
- Practice Patterns, Physicians'/economics
- Practice Patterns, Physicians'/standards
- Practice Patterns, Physicians'/statistics & numerical data
- Preventive Health Services/economics
- Preventive Health Services/standards
- Preventive Health Services/statistics & numerical data
- Quality Assurance, Health Care/economics
- Quality Assurance, Health Care/standards
- Quality Assurance, Health Care/trends
- Reimbursement, Incentive/economics
- Reimbursement, Incentive/standards
- Workload
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Affiliation(s)
- Jinhu Li
- Melbourne Institute of Applied Economic and Social Research, University of Melbourne, Carlton, VIC, Australia
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Honein-AbouHaidar GN, Rabeneck L, Paszat LF, Sutradhar R, Tinmouth J, Baxter NN. Evaluating the impact of public health initiatives on trends in fecal occult blood test participation in Ontario. BMC Cancer 2014; 14:537. [PMID: 25062552 PMCID: PMC4132913 DOI: 10.1186/1471-2407-14-537] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 07/09/2014] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND Since the publication of two randomized controlled trials (RCT) in 1996 demonstrating the effectiveness of fecal occult blood test (FOBT) in reducing colorectal cancer (CRC) mortality, several public health initiatives have been introduced in Ontario to promote FOBT participation. We examined the effect of these initiatives on FOBT participation and evaluated temporal trends in participation between 1994 and 2012. METHOD Using administrative databases, we identified 18 annual cohorts of individuals age 50 to 74 years eligible for CRC screening and identified those who received FOBT in each quarter of a year. We used negative binomial segmented regression to examine the effect of initiatives on trends and Joinpoint regression to evaluate temporal trends in FOBT participation. RESULTS Quarterly FOBT participation increased from 6.5 per 1000 in quarter 1 to 41.6 per 1000 in quarter 72 (January-March 2012). Segmented regression indicated increases following the publication of the RCTs in 1996 (Δ slope = 6%, 95% CI = 4.3-7.9), the primary care physician financial incentives announcement in 2005 (Δ slope = 2.2%, 95% CI = 0.68-3.7), the launch of the ColonCancerCheck (CCC) Program (Δ intercept = 35.4%, 95% CI = 18.3 -54.9), and the CCC Program 2-year anniversary (Δ slope = 7.2%, 95% CI = 3.9 - 10.5). Joinpoint validated these findings and identified the specific points when changes occurred. CONCLUSION Although observed increases in FOBT participation cannot be definitively attributed to the various initiatives, the results of the two statistical approaches suggest a causal association between the observed increases in FOBT participation and most of these initiatives.
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Affiliation(s)
| | - Linda Rabeneck
- />Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- />Prevention and Cancer Control, Cancer Care Ontario, Toronto, ON Canada
- />Department of Medicine, University of Toronto, Toronto, ON Canada
- />Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON Canada
- />Institute for Clinical Evaluative Sciences, Toronto, ON Canada
| | - Lawrence F Paszat
- />Institute for Clinical Evaluative Sciences, Toronto, ON Canada
- />Sunnybrook Research Institute, Toronto, ON Canada
| | - Rinku Sutradhar
- />Dalla Lana School of Public Health, University of Toronto, Toronto, ON Canada
- />Institute for Clinical Evaluative Sciences, Toronto, ON Canada
| | - Jill Tinmouth
- />Department of Medicine, University of Toronto, Toronto, ON Canada
- />Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON Canada
- />Institute for Clinical Evaluative Sciences, Toronto, ON Canada
- />Sunnybrook Research Institute, Toronto, ON Canada
- />ColonCancerCheck Program, Cancer Care Ontario, Toronto, ON Canada
| | - Nancy N Baxter
- />Institute for Health Policy Management and Evaluation, University of Toronto, Toronto, ON Canada
- />Institute for Clinical Evaluative Sciences, Toronto, ON Canada
- />Department of Surgery and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, ON Canada
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Kiran T, Wilton AS, Moineddin R, Paszat L, Glazier RH. Effect of payment incentives on cancer screening in Ontario primary care. Ann Fam Med 2014; 12:317-23. [PMID: 25024239 PMCID: PMC4096468 DOI: 10.1370/afm.1664] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE There is limited evidence for the effectiveness of pay for performance despite its widespread use. We assessed whether the introduction of a pay-for-performance scheme for primary care physicians in Ontario, Canada, was associated with increased cancer screening rates and determined the amounts paid to physicians as part of the program. METHODS We performed a longitudinal analysis using administrative data to determine cancer screening rates and incentive costs in each fiscal year from 1999/2000 to 2009/2010. We used a segmented linear regression analysis to assess whether there was a step change or change in screening rate trends after incentives were introduced in 2006/2007. We included all Ontarians eligible for cervical, breast, and colorectal cancer screening. RESULTS We found no significant step change in the screening rate for any of the 3 cancers the year after incentives were introduced. Colon cancer screening was increasing at a rate of 3.0% (95% CI, 2.3% to 3.7%) per year before the incentives were introduced and 4.7% (95% CI, 3.7% to 5.7%) per year after. The cervical and breast cancer screening rates did not change significantly from year to year before or after the incentives were introduced. Between 2006/2007 and 2009/2010, $28.3 million, $31.3 million, and $50.0 million were spent on financial incentives for cervical, breast, and colorectal cancer screening, respectively. CONCLUSIONS The pay-for-performance scheme was associated with little or no improvement in screening rates despite substantial expenditure. Policy makers should consider other strategies for improving rates of cancer screening.
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Affiliation(s)
- Tara Kiran
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada Department of Family and Community Medicine, University of Toronto, Ontario, Canada
| | - Andrew S Wilton
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Rahim Moineddin
- Department of Family and Community Medicine, University of Toronto, Ontario, Canada Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Dalla Lana School of Public Health, Toronto, Ontario, Canada
| | - Lawrence Paszat
- Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Richard H Glazier
- Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, Ontario, Canada Department of Family and Community Medicine, St. Michael's Hospital, Toronto, Ontario, Canada Department of Family and Community Medicine, University of Toronto, Ontario, Canada Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada Dalla Lana School of Public Health, Toronto, Ontario, Canada
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Pope B, Deshmukh A, Johnson A, Rohack J. Multilateral contracting and prevention. HEALTH ECONOMICS 2014; 23:397-409. [PMID: 23554156 DOI: 10.1002/hec.2920] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/18/2011] [Revised: 12/20/2012] [Accepted: 02/15/2013] [Indexed: 06/02/2023]
Abstract
Incentives created through contracts can be used as a means of decentralized control in healthcare systems to ensure more efficient healthcare. In this paper, we consider an insurer contracting with a consumer and a provider. We focus on the trade-off between ex ante moral hazard and insurance, and consider both consumer and provider incentives in the insurer's contracting problem in the presence of unobservable preventive efforts. We study two cases of provider efforts: those that complement consumer efforts and those that substitute for consumer efforts. In the first case, our results show that the provider must have greater incentives when the consumer is healthy to induce effort and that inducing provider effort allows an insurer to offer a more complete insurance contract relative to the bilateral benchmark. In the second case, we state conditions under which these conclusions continue to hold. On the basis of our findings, we discuss the implications and challenges of multilateral contracting in practice.
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Affiliation(s)
- Brandon Pope
- School of Industrial Engineering, Regenstrief Center for Healthcare Engineering, Purdue University, West Lafayette, IN, USA
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Pearce M, Catleugh M. Are general dental practitioners providing best practice in prevention in everyday general practice? Prim Dent J 2014; 2:38-43. [PMID: 24340497 DOI: 10.1308/205016813807440092] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
AIMS To discover whether general dental practitioners are providing best practice in prevention, as defined by the 'Delivering Better Oral Health' toolkit, in everyday general practice. METHOD A questionnaire was created with five scenarios describing the key findings of the examination of five hypothetical patients. Dentists attending a postgraduate meeting were asked to list all the preventive treatment and advice they would give each patient. The content of their answers was compared with the toolkit by two researchers. RESULTS Twenty four dentists completed the questionnaire. In general terms, they did not mention much of the specific advice or recommend the treatment listed in the toolkit except that a significant proportion would apply fluoride varnish to children's teeth and all would give smoking cessation advice where appropriate. Suitable recall intervals, defined by the National Institute for Clinical Excellence, were suggested for three of the scenarios but the advice was inconsistent for the other two scenarios. CONCLUSION This small investigation suggests that dentists' implementation of prevention, as advised by the toolkit, is not thorough or consistent. Comprehensive adoption of prevention in dentistry will require intensive multifaceted education and organisational change such as might be provided by the new contracts being piloted at present.
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Kantarevic J, Kralj B. Link between pay for performance incentives and physician payment mechanisms: evidence from the diabetes management incentive in Ontario. HEALTH ECONOMICS 2013; 22:1417-1439. [PMID: 23203722 DOI: 10.1002/hec.2890] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2012] [Revised: 09/06/2012] [Accepted: 11/02/2012] [Indexed: 05/25/2023]
Abstract
Pay for performance (P4P) incentives for physicians are generally designed as additional payments that can be paired with any existing payment mechanism such as a salary, fee-for-services and capitation. However, the link between the physician response to performance incentives and the existing payment mechanisms is still not well understood. In this article, we study this link using the recent primary care physician payment reform in Ontario as a natural experiment and the Diabetes Management Incentive as a case study. Using a comprehensive administrative data strategy and a difference-in-differences matching strategy, we find that physicians in a blended capitation model are more responsive to the Diabetes Management Incentive than physicians in an enhanced fee-for-service model. We show that this result implies that the optimal size of P4P incentives vary negatively with the degree of supply-side cost-sharing. These results have important implications for the design of P4P programs and the cost of their implementation.
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Affiliation(s)
- Jasmin Kantarevic
- Ontario Medical Association, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada; Institute for Labor Studies, Bonn, Germany
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Chandran M. Fracture Liaison Services in an open system: how was it done? what were the barriers and how were they overcome? Curr Osteoporos Rep 2013; 11:385-90. [PMID: 24026312 DOI: 10.1007/s11914-013-0162-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
A fragility fracture signals the potential for the occurrence of a subsequent fracture, and it often represents the first opportunity for care of osteoporosis. It is now well accepted knowledge that fracture liaison services can close or, at the very least, narrow the care gap that exists in the management of these sentinel events in patients with osteoporosis. The challenge, however, lies in translating this knowledge into practice and to implement these programs in health care systems with varied infrastructure and delivery practices operating in varied geographical environments. A review of a functioning model of care in an open health system in an Asian country and a short account of the problems encountered and the lessons learned during the course of its implementation are provided.
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Affiliation(s)
- Manju Chandran
- Osteoporosis and Bone Metabolism Unit, Department of Endocrinology, Singapore General Hospital and DUKE-NUS Graduate Medical School, ACADEMIA, 20 College Rd, Singapore, 169856, Singapore,
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Ryan AM, Damberg CL. What can the past of pay-for-performance tell us about the future of Value-Based Purchasing in Medicare? HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2013; 1:42-9. [PMID: 26249639 DOI: 10.1016/j.hjdsi.2013.04.006] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 04/15/2013] [Accepted: 04/21/2013] [Indexed: 10/26/2022]
Abstract
The Medicare program has implemented pay-for-performance (P4P), or Value-Based Purchasing, for inpatient care and for Medicare Advantage plans, and plans to implement a program for physicians in 2015. In this paper, we review evidence on the effectiveness of P4P and identify design criteria deemed to be best practice in P4P. We then assess the extent to which Medicare's existing and planned Value-Based Purchasing programs align with these best practices. Of the seven identified best practices in P4P program design, the Hospital Value-Based Purchasing program is strongly aligned with two of the best practices, moderately aligned with three, weakly aligned with one, and has unclear alignment with one best practice. The Physician Value-Based Purchasing Modifier is strongly aligned with two of the best practices, moderately aligned with one, weakly aligned with three, and has unclear alignment with one of the best practices. The Medicare Advantage Quality Bonus Program is strongly aligned with four of the best practices, moderately aligned with two, and weakly aligned with one of the best practices. We identify enduring gaps in P4P literature as it relates to Medicare's plans for Value-Based Purchasing and discuss important issues in the future of these implementations in Medicare.
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Affiliation(s)
- Andrew M Ryan
- Department of Public Health, Weill Cornell Medical College, 402 East 67th Street, New York, NY, USA.
| | - Cheryl L Damberg
- RAND Corporation and Pardee RAND Graduate School, Santa Monica, CA, USA
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Effects of pay for performance in health care: A systematic review of systematic reviews. Health Policy 2013; 110:115-30. [DOI: 10.1016/j.healthpol.2013.01.008] [Citation(s) in RCA: 250] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Revised: 01/09/2013] [Accepted: 01/11/2013] [Indexed: 12/25/2022]
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Halvorsen PA, Steinert S, Aaraas IJ. Remuneration and organization in general practice: do GPs prefer private practice or salaried positions? Scand J Prim Health Care 2012; 30:229-33. [PMID: 23050804 PMCID: PMC3520417 DOI: 10.3109/02813432.2012.711191] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVE In Norway the default payment option for general practice is a patient list system based on private practice, but other options exist. This study aimed to explore whether general practitioners (GPs) prefer private practice or salaried positions. DESIGN Cross-sectional online survey (QuestBack). SETTING General practice in Norway. INTERVENTION Participants were asked whether their current practice was based on (1) private practice in which the GP holds office space, equipment, and employs the staff, (2) private practice in which the GPs hire office space, equipment, or staff from the municipality, (3) salary with bonus arrangements, or (4) salary without bonus arrangement. Furthermore, they were asked which of these options they would prefer if they could choose. SUBJECTS GPs in Norway (n = 3270). MAIN OUTCOME MEASURES Proportion of GPs who preferred private practice. RESULTS Responses were obtained from 1304 GPs (40%). Among these, 75% were currently in private practice, 18% in private practice with some services provided by the municipality, 4% had a fixed salary plus a proportion of service fees, whereas 3% had salary only. Corresponding figures for the preferred option were 52%, 26%, 16%, and 6%, respectively. In multivariate logistic regression analysis, size of municipality, specialty attainment, and number of patients listed were associated with preference for private practice. CONCLUSION The majority of Norwegian GPs had and preferred private practice, but a significant minority would prefer a salaried position. The current private practice based system in Norway seems best suited to the preferences of experienced GPs in urban communities.
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Affiliation(s)
- Peder A Halvorsen
- National Centre of Rural Medicine, Department of Community Medicine, University of Tromsø, Norway.
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Gillam SJ, Siriwardena AN, Steel N. Pay-for-performance in the United Kingdom: impact of the quality and outcomes framework: a systematic review. Ann Fam Med 2012; 10:461-8. [PMID: 22966110 PMCID: PMC3438214 DOI: 10.1370/afm.1377] [Citation(s) in RCA: 180] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Primary care practices in the United Kingdom have received substantial financial rewards for achieving standards set out in the Quality and Outcomes Framework since April 2004. This article reviews the growing evidence for the impact of the framework on the quality of primary medical care. METHODS Five hundred seventy-five articles were identified by searching the MEDLINE, EMBASE, and PsycINFO databases, and from the reference lists of published reviews and articles. One hundred twenty-four relevant articles were assessed using a modified Downs and Black rating scale for 110 observational studies and a Critical Appraisal Skills Programme rating scale for 14 qualitative studies. Ninety-four studies were included in the review. RESULTS Quality of care for incentivized conditions during the first year of the framework improved at a faster rate than the preintervention trend and subsequently returned to prior rates of improvement. There were modest cost-effective reductions in mortality and hospital admissions in some domains. Differences in performance narrowed in deprived areas compared with nondeprived areas. Achievement for conditions outside the framework was lower initially and has worsened in relative terms since inception. Some doctors reported improved data recording and teamwork, and nurses enhanced specialist skills. Both groups believed that the person-centeredness of consultations and continuity were negatively affected. Patients' satisfaction with continuity declined, with little change in other domains of patient experience. CONCLUSIONS Observed improvements in quality of care for chronic diseases in the framework were modest, and the impact on costs, professional behavior, and patient experience remains uncertain. Further research is needed into how to improve quality across different domains, while minimizing costs and any unintended adverse effects of payment for performance schemes. Health care organizations should remain cautious about the benefits of similar schemes.
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Affiliation(s)
- Stephen J Gillam
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Cambridge, England, UK.
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Eirea Eiras C, Ortún Rubio V. Incentivos financieros en la mejora de la calidad asistencial. Informe SESPAS 2012. GACETA SANITARIA 2012; 26 Suppl 1:102-6. [DOI: 10.1016/j.gaceta.2011.11.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 11/06/2011] [Accepted: 11/15/2011] [Indexed: 11/28/2022]
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Robertson C, Rose S, Kesselheim AS. Effect of financial relationships on the behaviors of health care professionals: a review of the evidence. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2012; 40:452-466. [PMID: 23061573 DOI: 10.1111/j.1748-720x.2012.00678.x] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
This paper explores the empirical evidence regarding the impact financial relationships on the behavior of health care providers, specifically, physicians. We identify and synthesize peer-reviewed data addressing whether financial incentives are causally related to patient outcomes and health care costs. We cover three main areas where financial conflicts of interest arise and may have an observable relationship to health care practices: (1) physicians' roles as self-referrers, (2) insurance reimbursement schemes that create incentives for certain clinical choices over others, and (3) financial relationships between physicians and the drug and device industries. We found a well-developed scientific literature consisting of dozens of empirical studies, some that allow stronger causal inferences than others, but which altogether show that such financial conflicts of interests can, and sometimes do, impact physicians' clinical decisions. Further research is warranted to document the causal relationship of such changes on health outcomes and the cost of care, but the current base of evidence is sufficiently robust to motivate policy reform.
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A health insurance company-initiated practice support intervention for optimizing acid-suppressing drug prescriptions in primary care. Eur J Gastroenterol Hepatol 2011; 23:664-70. [PMID: 21673577 DOI: 10.1097/meg.0b013e328347d503] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND A health insurance-initiated programme to improve cost-effectiveness of acid-suppressing drugs (ASDs). AIM To evaluate the effect of two different interventions of general practitioner support in reducing drug prescription. MATERIALS AND METHODS A sequential cluster randomized controlled trial with 90 participating general practitioners in a telephone support (TS) group or practice visit (PV) group. TS group received support in phase-1 (first 6 months), but served as control group in phase-2 (6-12 months period). PV group received no intervention in phase-1, serving as the control group for the TS group, but received support in phase-2. Prescription data were extracted from Agis Health Insurance Database. Outcomes were the proportion of responders to drug reduction and the number of defined daily dose (DDD). Differences in users and DDD were analysed using multilevel regression analysis. RESULTS At baseline, 3424 patients used ASD chronically (211 DDDs, on average). The difference between TS and control groups among responders was 3.2% [95% confidence interval (CI): 0.8; 5.6] and relative risk was 1.26 (95% CI: 1.06; 1.51). The difference between PV and control groups was not relevant (0.4%, 95% CI: -1.99; 2.79 and relative risk: 1.01, 95% CI: 0.82; 1.20). The difference in DDD per patient was -3.0 (95% CI: -8.9; 2.9) and -5.82 (95% CI: -12.4; 0.73), respectively. CONCLUSION This health insurance company-initiated intervention had a moderate effect on ASD prescription. In contrast to TS, PVs did not seem to reduce ASD prescription rates.
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Flodgren G, Eccles MP, Shepperd S, Scott A, Parmelli E, Beyer FR. An overview of reviews evaluating the effectiveness of financial incentives in changing healthcare professional behaviours and patient outcomes. Cochrane Database Syst Rev 2011; 2011:CD009255. [PMID: 21735443 PMCID: PMC4204491 DOI: 10.1002/14651858.cd009255] [Citation(s) in RCA: 184] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND There is considerable interest in the effectiveness of financial incentives in the delivery of health care. Incentives may be used in an attempt to increase the use of evidence-based treatments among healthcare professionals or to stimulate health professionals to change their clinical behaviour with respect to preventive, diagnostic and treatment decisions, or both. Financial incentives are an extrinsic source of motivation and exist when an individual can expect a monetary transfer which is made conditional on acting in a particular way. Since there are numerous reviews performed within the healthcare area describing the effects of various types of financial incentives, it is important to summarise the effectiveness of these in an overview to discern which are most effective in changing health professionals' behaviour and patient outcomes. OBJECTIVES To conduct an overview of systematic reviews that evaluates the impact of financial incentives on healthcare professional behaviour and patient outcomes. METHODS We searched the Cochrane Database of Systematic Reviews (CDSR) (The Cochrane Library); Database of Abstracts of Reviews of Effectiveness (DARE); TRIP; MEDLINE; EMBASE; Science Citation Index; Social Science Citation Index; NHS EED; HEED; EconLit; and Program in Policy Decision-Making (PPd) (from their inception dates up to January 2010). We searched the reference lists of all included reviews and carried out a citation search of those papers which cited studies included in the review. We included both Cochrane and non-Cochrane reviews of randomised controlled trials (RCTs), controlled clinical trials (CCTs), interrupted time series (ITSs) and controlled before and after studies (CBAs) that evaluated the effects of financial incentives on professional practice and patient outcomes, and that reported numerical results of the included individual studies. Two review authors independently extracted data and assessed the methodological quality of each review according to the AMSTAR criteria. We included systematic reviews of studies evaluating the effectiveness of any type of financial incentive. We grouped financial incentives into five groups: payment for working for a specified time period; payment for each service, episode or visit; payment for providing care for a patient or specific population; payment for providing a pre-specified level or providing a change in activity or quality of care; and mixed or other systems. We summarised data using vote counting. MAIN RESULTS We identified four reviews reporting on 32 studies. Two reviews scored 7 on the AMSTAR criteria (moderate, score 5 to 7, quality) and two scored 9 (high, score 8 to 11, quality). The reported quality of the included studies was, by a variety of methods, low to moderate. Payment for working for a specified time period was generally ineffective, improving 3/11 outcomes from one study reported in one review. Payment for each service, episode or visit was generally effective, improving 7/10 outcomes from five studies reported in three reviews; payment for providing care for a patient or specific population was generally effective, improving 48/69 outcomes from 13 studies reported in two reviews; payment for providing a pre-specified level or providing a change in activity or quality of care was generally effective, improving 17/20 reported outcomes from 10 studies reported in two reviews; and mixed and other systems were of mixed effectiveness, improving 20/31 reported outcomes from seven studies reported in three reviews. When looking at the effect of financial incentives overall across categories of outcomes, they were of mixed effectiveness on consultation or visit rates (improving 10/17 outcomes from three studies in two reviews); generally effective in improving processes of care (improving 41/57 outcomes from 19 studies in three reviews); generally effective in improving referrals and admissions (improving 11/16 outcomes from 11 studies in four reviews); generally ineffective in improving compliance with guidelines outcomes (improving 5/17 outcomes from five studies in two reviews); and generally effective in improving prescribing costs outcomes (improving 28/34 outcomes from 10 studies in one review). AUTHORS' CONCLUSIONS Financial incentives may be effective in changing healthcare professional practice. The evidence has serious methodological limitations and is also very limited in its completeness and generalisability. We found no evidence from reviews that examined the effect of financial incentives on patient outcomes.
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Affiliation(s)
- Gerd Flodgren
- University of OxfordDepartment of Public HealthRosemary Rue BuildingOld Road CampusHeadingtonOxfordUKOX3 7LF
| | - Martin P Eccles
- Newcastle UniversityInstitute of Health and SocietyBadiley Clark BuildingRichardson RoadNewcastle upon TyneUKNE2 4AX
| | - Sasha Shepperd
- University of OxfordDepartment of Public HealthRosemary Rue BuildingHeadingtonOxfordOxfordshireUKOX3 7LF
| | - Anthony Scott
- The University of MelbourneMelbourne Institute of Applied Economic and Social ResearchLevel 7, Alan Gilbert BuildingBarry StreetCarlton, MelbourneVICAustralia3053
| | - Elena Parmelli
- University of Modena and Reggio EmiliaDepartment of Oncology, Hematology and Respiratory DiseasesVia del Pozzo 71ModenaItaly41100
| | - Fiona R Beyer
- University of YorkCentre for Reviews and DisseminationYorkUKYO10 5DD
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