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Feng Y, Kristensen SR, Lorgelly P, Meacock R, Núñez-Elvira A, Rodés-Sánchez M, Siciliani L, Sutton M. Pay-for-Performance incentives for specialised services in England: a mixed methods evaluation. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:857-876. [PMID: 37831298 DOI: 10.1007/s10198-023-01630-6] [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: 02/24/2023] [Accepted: 09/11/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND A Pay-for-Performance (P4P) programme, known as Prescribed Specialised Services Commissioning for Quality and Innovation (PSS CQUIN), was introduced for specialised services in the English NHS in 2013/2014. These services treat patients with rare and complex conditions. We evaluate the implementation of PSS CQUIN contracts between 2016/2017 and 2018/2019. METHODS We used a mixed methods evaluative approach. In the quantitative analysis, we used a difference-in-differences design to evaluate the effectiveness of ten PSS CQUIN schemes across a range of targeted outcomes. Potential selection bias was addressed using propensity score matching. We also estimated impacts on costs by scheme and financial year. In the qualitative analysis, we conducted semi-structured interviews and focus group discussions to gain insights into the complexities of contract design and programme implementation. Qualitative data analysis was based on the constant comparative method, inductively generating themes. RESULTS The ten PSS CQUIN schemes had limited impact on the targeted outcomes. A statistically significant improvement was found for only one scheme: in the clinical area of trauma, the incentive scheme increased the probability of being discharged from Adult Critical Care within four hours of being clinically ready by 7%. The limited impact may be due to the size of the incentive payments, the complexity of the schemes' design, and issues around ownership, contracting and flexibility. CONCLUSION The PSS CQUIN schemes had little or no impact on quality improvements in specialised services. Future P4P programmes in healthcare could benefit from lessons learnt from this study on incentive design and programme implementation.
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Affiliation(s)
- Yan Feng
- Centre for Evaluation and Methods, Queen Mary University of London, Yvonne Carter Building, 58 Turner Street, Whitechapel, London, E1 2AB, UK.
| | - Søren Rud Kristensen
- Institute of Global Health Innovation, Imperial College London, London, UK
- Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
| | - Paula Lorgelly
- Faculty of Medical and Health Sciences and School of Business, University of Auckland, Auckland, New Zealand
- Department of Applied Health Research, University College London, London, UK
| | - Rachel Meacock
- Health Organisation, Policy and Economics, University of Manchester, Manchester, UK
| | | | | | - Luigi Siciliani
- Department of Economics and Related Studies, University of York, York, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics, University of Manchester, Manchester, UK
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Russo LX, Powell-Jackson T, Borghi J, Sampaio J, Gurgel Junior GD, Shimizu HE, Bezerra AFB, E Silva KSDB, Barreto JOM, de Carvalho ALB, Kovacs RJ, Gomes LB, Fardousi N, da Silva EN. Does pay-for-performance design matter? Evidence from Brazil. Health Policy Plan 2024; 39:593-602. [PMID: 38661300 PMCID: PMC11145906 DOI: 10.1093/heapol/czae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 02/14/2024] [Accepted: 04/23/2024] [Indexed: 04/26/2024] Open
Abstract
Pay-for-performance (P4P) schemes have been shown to have mixed effects on health care outcomes. A challenge in interpreting this evidence is that P4P is often considered a homogenous intervention, when in practice schemes vary widely in their design. Our study contributes to this literature by providing a detailed depiction of incentive design across municipalities within a national P4P scheme in Brazil [Primary Care Access and Quality (PMAQ)] and exploring the association of alternative design typologies with the performance of primary health care providers. We carried out a nation-wide survey of municipal health managers to characterize the scheme design, based on the size of the bonus, the providers incentivized and the frequency of payment. Using OLS regressions and controlling for municipality characteristics, we examined whether each design feature was associated with better family health team (FHT) performance. To capture potential interactions between design features, we used cluster analysis to group municipalities into five design typologies and then examined associations with quality of care. A majority of the municipalities included in our study used some of the PMAQ funds to provide bonuses to FHT workers, while the remaining municipalities spent the funds in the traditional way using input-based budgets. Frequent bonus payments (monthly) and higher size bonus allocations (share of 20-80%) were strongly associated with better team performance, while who within a team was eligible to receive bonuses did not in isolation appear to influence performance. The cluster analysis showed what combinations of design features were associated with better performance. The PMAQ score in the 'large bonus/many workers/high-frequency' cluster was 8.44 points higher than the 'no bonus' cluster, equivalent to a difference of 21.7% in the mean PMAQ score. Evidence from our study shows how design features can potentially influence health provider performance, informing the design of more effective P4P schemes.
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Affiliation(s)
- Letícia Xander Russo
- Faculty of Business, Accounting and Economics, Federal University of Grande Dourados, Rodovia Dourados—Itahum, Km 12, Dourados, MS 79804-970, Brazil
| | - Timothy Powell-Jackson
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom
| | - Josephine Borghi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom
| | - Juliana Sampaio
- Department of Health Promotion, Federal University of Paraiba, João Pessoa 58051-900, Brazil
| | | | - Helena Eri Shimizu
- Department of Collective Health, University of Brasilia, Brasilia 70910-900, Brazil
| | | | - Keila Silene de Brito E Silva
- Collective Health Nucleous, Academic Center of Vitória, Federal University of Pernambuco, Vitória de Santo Antão 55608-680, Brazil
| | | | | | - Roxanne J Kovacs
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom
| | - Luciano Bezerra Gomes
- Department of Health Promotion, Federal University of Paraiba, João Pessoa 58051-900, Brazil
| | - Nasser Fardousi
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, London WC1E 7HT, United Kingdom
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Rutter MK, Carr MJ, Wright AK, Kanumilli N, Milne N, Jones E, Elton P, Ceriello A, Misra A, Del Prato S, Barron E, Hambling C, Sattar N, Khunti K, Valabhji J, Feldman EL, Ashcroft DM. Indirect effects of the COVID-19 pandemic on diagnosing, monitoring, and prescribing in people with diabetes and strategies for diabetes service recovery internationally. Diabetes Res Clin Pract 2024; 212:111693. [PMID: 38719027 DOI: 10.1016/j.diabres.2024.111693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Revised: 04/30/2024] [Accepted: 05/02/2024] [Indexed: 05/23/2024]
Abstract
The COVID-19 pandemic has caused major disruptions in clinical services for people with chronic long-term conditions. In this narrative review, we assess the indirect impacts of the COVID-19 pandemic on diabetes services globally and the resulting adverse effects on rates of diagnosing, monitoring, and prescribing in people with type 2 diabetes. We summarise potential practical approaches that could address these issues and improve clinical services and outcomes for people living with diabetes during the recovery phase of the pandemic.
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Affiliation(s)
- Martin K Rutter
- Faculty of Medicine, Biology and Health, University of Manchester, Manchester M13 9PL, United Kingdom; Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester M13 0JE, United Kingdom.
| | - Matthew J Carr
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Manchester, United Kingdom; NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, United Kingdom
| | - Alison K Wright
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, The University of Manchester, Manchester, United Kingdom
| | - Naresh Kanumilli
- Diabetes, Endocrinology and Metabolism Centre, Manchester University NHS Foundation Trust, Manchester Academic Health Science Centre, NIHR Manchester Biomedical Research Centre, Manchester M13 0JE, United Kingdom
| | - Nicola Milne
- Brooklands and Northenden Primary Care Network, Greater Manchester, United Kingdom
| | - Ewan Jones
- Greater Manchester & Eastern Cheshire Strategic Clinical Networks, NHS Greater Manchester Integrated Care, United Kingdom
| | - Peter Elton
- Greater Manchester & Eastern Cheshire Strategic Clinical Networks, NHS Greater Manchester Integrated Care, United Kingdom
| | | | - Anoop Misra
- Fortis C-DOC Centre of Excellence for Diabetes, Metabolic Diseases and Endocrinology, Chirag Enclave, National Diabetes Obesity and Cholesterol Foundation and Diabetes Foundation (India), New Delhi, India
| | - Stefano Del Prato
- Department of Clinical and Experimental Medicine, Section of Metabolic Diseases and Diabetes, University of Pisa, Pisa, Italy
| | - Emma Barron
- NHS England, Wellington House, 122-135 Waterloo Road, London, UK; Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK; Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Clare Hambling
- NHS England, Wellington House, 122-135 Waterloo Road, London, UK; Bridge Street Surgery, Norfolk, United Kingdom
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Kamlesh Khunti
- Diabetes Research Centre, University of Leicester, Leicester, United Kingdom
| | - Jonathan Valabhji
- NHS England, Wellington House, 122-135 Waterloo Road, London, UK; Department of Metabolism, Digestion and Reproduction, Faculty of Medicine, Imperial College London, London, UK; Chelsea and Westminster Hospital NHS Foundation Trust, London, UK
| | - Eva L Feldman
- Department of Neurology, University of Michigan, Ann Arbor, MI, USA
| | - Darren M Ashcroft
- NIHR Greater Manchester Patient Safety Research Collaboration, University of Manchester, Manchester, United Kingdom; Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Oxford Road, Manchester M13 9PL, United Kingdom
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Slawomirski L, Hensher M, Campbell J, deGraaff B. Pay-for-performance and patient safety in acute care: A systematic review. Health Policy 2024; 143:105051. [PMID: 38547664 DOI: 10.1016/j.healthpol.2024.105051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/13/2024] [Accepted: 03/17/2024] [Indexed: 04/20/2024]
Abstract
Pay-for-performance (p4p) has been tried in all healthcare settings to address ongoing deficiencies in the quality and outcomes of care. The evidence for the effect of these policies has been inconclusive, especially in acute care. This systematic review focused on patient safety p4p in the hospital setting. Using the PRISMA guidelines, we searched five biomedical databases for quantitative studies using at least one outcome metric from database inception to March 2023, supplemented by reference tracking and internet searches. We identified 6,122 potential titles of which 53 were included: 39 original investigations, eight literature reviews and six grey literature reports. Only five system-wide p4p policies have been implemented, and the quality of evidence was low overall. Just over half of the studies (52 %) included failed to observe improvement in outcomes, with positive findings heavily skewed towards poor quality evaluations. The exception was the Fragility Hip Fracture Best Practice Tariff (BPT) in England, where sustained improvement was observed across various evaluations. All policies had a miniscule impact on total hospital revenue. Our findings underscore the importance of simple and transparent design, involvement of the clinical community, explicit links to other quality improvement initiatives, and gradual implementation of p4p initatives. We also propose a research agenda to lift the quality of evidence in this field.
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Affiliation(s)
- Luke Slawomirski
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St., Hobart 7000, Tasmania, Australia.
| | - Martin Hensher
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St., Hobart 7000, Tasmania, Australia
| | - Julie Campbell
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St., Hobart 7000, Tasmania, Australia
| | - Barbara deGraaff
- Menzies Institute for Medical Research, University of Tasmania, 17 Liverpool St., Hobart 7000, Tasmania, Australia
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5
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Ishida R, Koga K, Ohbe H, Izumi G, Matsui H, Yasunaga H, Osuga Y. Impact of government-issued financial incentive to medical facilities on management of secondary dysmenorrhea. J Obstet Gynaecol Res 2024. [PMID: 38597093 DOI: 10.1111/jog.15946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/31/2024] [Indexed: 04/11/2024]
Abstract
AIM In April 2020, the Japanese government introduced a Specific Medical Fee for managing secondary dysmenorrhea (SD). This initiative provided financial incentives to medical facilities that provide appropriate management of SD with hormonal therapies. We aimed to assess how this policy affects the management processes and outcomes of patients with SD. METHODS Using a large Japanese administrative claims database, we identified outpatient visits of patients diagnosed with SD from April 2018 to March 2022. We used an interrupted time-series analysis and defined before April 2020 as the pre-introduction period and after April 2020 as the post-introduction period. Outcomes were the monthly proportions of outpatient visits due to SD and hormonal therapy among women in the database and the proportions of outpatient visits for hormonal therapy and continuous outpatient visits among patients with SD. RESULTS We identified 815 477 outpatient visits of patients diagnosed with SD during the pre-introduction period and 920 183 outpatient visits during the post-introduction period. There were significant upward slope changes after the introduction of financial incentives in the outpatient visits due to SD (+0.29% yearly; 95% confidence interval, +0.20% to +0.38%) and hormonal therapies (+0.038% yearly; 95% confidence interval, +0.030% to +0.045%) among the women in the database. Similarly, a significant level change was observed after the introduction of continuous outpatient visits among patients with SD (+2.68% monthly; 95% confidence interval, +0.87% to +4.49%). CONCLUSIONS Government-issued financial incentives were associated with an increase in the number of patients diagnosed with SD, hormonal therapies, and continuous outpatient visits.
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Affiliation(s)
- Risa Ishida
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Reproductive Medicine, Chiba University, Chiba, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Gentaro Izumi
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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6
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Blonigen DM, Humphreys K. A Randomized Controlled Trial of a Pay-for-Performance Initiative to Reduce Costs of Care for High-Need Psychiatric Patients. Psychiatr Serv 2024:appips20230481. [PMID: 38566562 DOI: 10.1176/appi.ps.20230481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/04/2024]
Abstract
OBJECTIVE Pay-for-performance (P4P) initiatives hold promise for improving health care delivery but are rarely applied to behavioral health or tested in randomized controlled trials (RCTs). This RCT examined the effectiveness of a P4P initiative to reduce total cost of 24-hour care among patients with high needs for psychiatric care in a large county in California. METHODS From August 2016 to March 2022, a total of 652 adult residents of Santa Clara County, California, were enrolled in a P4P initiative (mean±SD age=46.7±13.3 years, 61% male, 51% White, and 60% diagnosed as having a bipolar or psychotic disorder). Participants were randomly assigned to usual full-service partnerships from the county (N=327) or a comparable level of care from a contractor who agreed to a schedule of financial penalties and rewards based on whether enrollees (N=325) used more or less care than a historical cohort of similar county patients. The primary outcome was total cost of 24-hour psychiatric services. Secondary outcomes were costs of each of the 24-hour care services. RESULTS The proportion of the total sample that used 24-hour psychiatric services decreased over the 36-month study period. Intent-to-treat analyses revealed no differences between the two study conditions in total care costs during the follow-up period. No significant care utilization differences were observed between the two conditions in most of the individual 24-hour services. CONCLUSIONS A P4P initiative for high-need patients was no more effective than usual care for reducing costs of 24-hour psychiatric care.
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Affiliation(s)
- Daniel M Blonigen
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, and Center for Innovation to Implementation, U.S. Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Keith Humphreys
- Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, and Center for Innovation to Implementation, U.S. Department of Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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7
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Kalata S, Reddy RM, Norton EC, Clark MJ, He C, Leyden T, Adams KN, Popoff AM, Lall SC, Lagisetty KH. Quality improvement mechanisms to improve lymph node staging for lung cancer: Trends from a statewide database. J Thorac Cardiovasc Surg 2024; 167:1469-1478.e3. [PMID: 37625618 DOI: 10.1016/j.jtcvs.2023.08.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 07/25/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023]
Abstract
OBJECTIVE Our statewide thoracic quality collaborative has implemented multiple quality improvement initiatives to improve lung cancer nodal staging. We subsequently implemented a value-based reimbursement initiative to further incentivize quality improvement. We compare the impact of these programs to steer future quality improvement initiatives. METHODS Since 2016, our collaborative focused on improving lymph node staging for lung cancer by leveraging unblinded, hospital-level metrics and collaborative feedback. In 2021, a value-based reimbursement initiative was implemented with statewide yearly benchmark rates for (1) preoperative mediastinal staging for ≥T2N0 lung cancer, and (2) sampling ≥5 lymph node stations. Participating surgeons would receive additional reimbursement if either benchmark was met. We reviewed patients from January 2015 to March 2023 at the 21 participating hospitals to determine the differential effects on quality improvement. RESULTS We analyzed 6228 patients. In 2015, 212 (39%) patients had ≥5 nodal stations sampled, and 99 (51%) patients had appropriate preoperative mediastinal staging. During 2016 to 2020, this increased to 2253 (62%) patients and 739 (56%) patients, respectively. After 2020, 1602 (77%) patients had ≥5 nodal stations sampled, and 403 (73%) patients had appropriate preoperative mediastinal staging. Interrupted time-series analysis demonstrated significant increases in adequate nodal sampling and mediastinal staging before value-based reimbursement. Afterward, preoperative mediastinal staging rates briefly dropped but significantly increased while nodal sampling did not change. CONCLUSIONS Collaborative quality improvement made significant progress before value-based reimbursement, which reinforces the effectiveness of leveraging unblinded data to a collaborative group of thoracic surgeons. Value-based reimbursement may still play a role within a quality collaborative to maintain infrastructure and incentivize participation.
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Affiliation(s)
- Stanley Kalata
- Department of Surgery, University of Michigan, Ann Arbor, Mich.
| | | | - Edward C Norton
- Departments of Health Management and Policy and Economics, University of Michigan, Ann Arbor, Mich
| | - Melissa J Clark
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich
| | - Chang He
- Michigan Society of Thoracic and Cardiovascular Surgeons Quality Collaborative, Ann Arbor, Mich
| | | | - Kumari N Adams
- Department of Thoracic Surgery, St. Joseph Mercy Hospital, Ann Arbor, Mich
| | - Andrew M Popoff
- Department of Thoracic Surgery, Henry Ford Hospital, Detroit, Mich
| | - Shelly C Lall
- Department of Thoracic Surgery, Munson Medical Center, Traverse City, Mich
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Abrantes T, Imbriano D, Reimann D, Sullivan J, Wisco O, Chan S, DiMarco C, Gehret N, Grenier N, Imbriano P, Kahn B, Lizbinski L, Massoud C, Negbenebor N, Parra S, Patel D, Reeder M, Robbins A, Takeshita J, Yang EJ, Braxton SC, Elston D. Performance measurement part I: Foundational knowledge for measure development. J Am Acad Dermatol 2024; 90:681-689. [PMID: 37343833 DOI: 10.1016/j.jaad.2023.01.054] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 12/21/2022] [Accepted: 01/11/2023] [Indexed: 06/23/2023]
Abstract
As medicine is moving toward performance and outcome-based payment and is transitioning away from productivity-based systems, value is now being appraised in healthcare through "performance measures." Over the past few decades, assessment of clinical performance in health care has been essential in ensuring safe and cost-effective patient care. The Centers for Medicare & Medicaid Services is further driving this change with measurable, outcomes-based national payer incentive payment systems. With the continually evolving requirements in health care reform focused on value-based care, there is a growing concern that clinicians, particularly dermatologists, may not understand the scientific rationale of health care quality measurement. As such, in order to help dermatologists understand the health care measurement science landscape to empower them to engage in the performance measure development and implementation process, the first article in this 2-part continuing medical education series reviews the value equation, historic and evolving policy issues, and the American Academy of Dermatology's approach to performance measurement development to provide the required foundational knowledge for performance measure developers.
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Affiliation(s)
- Tatiana Abrantes
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Dillon Imbriano
- University of New England College of Osteopathic Medicine, Biddeford, Maine
| | | | | | - Oliver Wisco
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island.
| | - Stephanie Chan
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Christopher DiMarco
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nicole Gehret
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nicole Grenier
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Paul Imbriano
- Berkshire Medical Center of Massachusetts, Pittsfield, Massachusetts
| | - Benjamin Kahn
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Leonardo Lizbinski
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Cathy Massoud
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Nicole Negbenebor
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Sylvia Parra
- Dermatology and Skin Surgery Incorporated of Sumter, Sumter, South Carolina
| | | | - Margo Reeder
- The University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Allison Robbins
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Junko Takeshita
- The University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Eric J Yang
- The Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | | | - Dirk Elston
- The Medical University of South Carolina, Charleston, South Carolina
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Oxholm AS, Gyrd-Hansen D, Jacobsen CB, Jensen UT, Pedersen LB. The link between physician motivation and care. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2024; 25:525-537. [PMID: 37353668 PMCID: PMC10972924 DOI: 10.1007/s10198-023-01605-7] [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: 02/08/2023] [Accepted: 06/06/2023] [Indexed: 06/25/2023]
Abstract
Studies report an unexplained variation in physicians' care. This variation may to some extent be explained by differences in their work motivation. However, empirical evidence on the link between physician motivation and care is scarce. We estimate the associations between different types of work motivation and care. Motivation is measured using validated questions from a nation-wide survey of Danish general practices and linked to high-quality register data on their care in 2019. Using a series of regression models, we find that more financially motivated practices generate more fee-for-services per patient, whereas practices characterised by greater altruistic motivation towards the patient serve a larger share of high-need patients and issue more prescriptions for antibiotics per patient. Practices with higher altruism towards society generate lower medication costs per patient and prescribe a higher rate of narrow-spectrum penicillin, thereby reducing the risk of antimicrobial resistance in the population. Together, our results suggest that practices' motivation is associated with several dimensions of healthcare, and that both their financial motivation and altruism towards patients and society play a role. Policymakers should, therefore, consider targeting all provider motivations when introducing organisational changes and incentive schemes; for example, by paying physicians to adhere to clinical guidelines, while at the same time clearly communicating the guidelines' value from both a patient and societal perspective.
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Affiliation(s)
- Anne Sophie Oxholm
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Odense, Denmark.
| | - Dorte Gyrd-Hansen
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Christian Bøtcher Jacobsen
- Crown Prince Frederik Center for Public Leadership, Department of Political Science and Government, Aarhus University, Aarhus, Denmark
| | - Ulrich Thy Jensen
- Crown Prince Frederik Center for Public Leadership, Department of Political Science and Government, Aarhus University, Aarhus, Denmark
- Center for Organization Research and Design, School of Public Affairs, Arizona State University, Phoenix, USA
| | - Line Bjørnskov Pedersen
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Odense, Denmark
- Research Unit for General Practice, University of Southern Denmark, Odense, Denmark
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10
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Anders A. Reconsidering performance management to support innovative changes in health care services. J Health Organ Manag 2024; 38:125-142. [PMID: 38546186 PMCID: PMC10988776 DOI: 10.1108/jhom-12-2022-0379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 12/15/2023] [Accepted: 02/18/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE A large number of studies indicate that coercive forms of organizational control and performance management in health care services often backfire and initiate dysfunctional consequences. The purpose of this article is to discuss new approaches to performance management in health care services when the purpose is to support innovative changes in the delivery of services. DESIGN/METHODOLOGY/APPROACH The article represents cross-boundary work as the theoretical and empirical material used to discuss and reconsider performance management comes from several relevant research disciplines, including systematic reviews of audit and feedback interventions in health care and extant theories of human motivation and organizational control. FINDINGS An enabling approach to performance management in health care services can potentially contribute to innovative changes. Key design elements to operationalize such an approach are a formative and learning-oriented use of performance measures, an appeal to self- and social-approval mechanisms when providing feedback and support for local goals and action plans that fit specific conditions and challenges. ORIGINALITY/VALUE The article suggests how to operationalize an enabling approach to performance management in health care services. The framework is consistent with new governance and managerial approaches emerging in public sector organizations more generally, supporting a higher degree of professional autonomy and the use of nonfinancial incentives.
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Affiliation(s)
- Anell Anders
- Department of Business Administration, Lund University
School of Economics and Management, Lund, Sweden
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11
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Wagenschieber E, Blunck D. Impact of reimbursement systems on patient care - a systematic review of systematic reviews. HEALTH ECONOMICS REVIEW 2024; 14:22. [PMID: 38492098 PMCID: PMC10944612 DOI: 10.1186/s13561-024-00487-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 02/07/2024] [Indexed: 03/18/2024]
Abstract
BACKGROUND There is not yet sufficient scientific evidence to answer the question of the extent to which different reimbursement systems influence patient care and treatment quality. Due to the asymmetry of information between physicians, health insurers and patients, market-based mechanisms are necessary to ensure the best possible patient care. The aim of this study is to investigate how reimbursement systems influence multiple areas of patient care in form of structure, process and outcome indicators. METHODS For this purpose, a systematic literature review of systematic reviews is conducted in the databases PubMed, Web of Science and the Cochrane Library. The reimbursement systems of salary, bundled payment, fee-for-service and value-based reimbursement are examined. Patient care is divided according to the three dimensions of structure, process, and outcome and evaluated in eight subcategories. RESULTS A total of 34 reviews of 971 underlying primary studies are included in this article. International studies identified the greatest effects in categories resource utilization and quality/health outcomes. Pay-for-performance and bundled payments were the most commonly studied models. Among the systems examined, fee-for-service and value-based reimbursement systems have the most positive impact on patient care. CONCLUSION Patient care can be influenced by the choice of reimbursement system. The factors for successful implementation need to be further explored in future research.
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Affiliation(s)
- Eva Wagenschieber
- Department of Healthcare Management, Institute of Management, Friedrich-Alexander-Universität Erlangen-Nürnberg, Lange Gasse 20, 90403, Nuremberg, Germany
| | - Dominik Blunck
- Department of Healthcare Management, Institute of Management, Friedrich-Alexander-Universität Erlangen-Nürnberg, Lange Gasse 20, 90403, Nuremberg, Germany.
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12
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Yordanov D, Oxholm AS, Prætorius T, Kristensen SR. Financial incentives for integrated care: A scoping review and lessons for evidence-based design. Health Policy 2024; 141:104995. [PMID: 38290390 DOI: 10.1016/j.healthpol.2024.104995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 01/11/2024] [Accepted: 01/14/2024] [Indexed: 02/01/2024]
Abstract
BACKGROUND In response to the increasing prevalence of people with chronic conditions, healthcare systems restructure to integrate care across providers. However, many systems fail to achieve the desired outcomes. One likely explanation is lack of financial incentives for integrating care. OBJECTIVES We aim to identify financial incentives used to promote integrated care across different types of providers for patients with common chronic conditions and assess the evidence on (cost-)effectiveness and the facilitators/barriers to their implementation. METHODS This scoping review identifies studies published before December 2021, and includes 33 studies from the United States and the Netherlands. RESULTS We identify four types of financial incentives: shared savings, bundled payments, pay for performance, and pay for coordination. Substantial heterogeneity in the (cost-)effectiveness of these incentives exists. Key implementation barriers are a lack of infrastructure (e.g., electronic medical records, communication channels, and clinical guidelines). To facilitate integration, financial incentives should be easy to communicate and implement, and require additional financial support, IT support, training, and guidelines. CONCLUSIONS All four types of financial incentives may promote integrated care but not in all contexts. Shared savings appears to be the most promising incentive type for promoting (cost-)effective care integration with the largest number of favourable studies allowing causal interpretations. The limited evidence pool makes it hard to draw firm conclusions that are transferable across contexts.
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Affiliation(s)
- Dimitar Yordanov
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
| | - Anne Sophie Oxholm
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
| | - Thim Prætorius
- Research Unit for Integrated Care and Prevention, Steno Diabetes Centre Aarhus, Aarhus University Hospital, Palle Juul-Jensens Boulevard 11, 8200 Aarhus N, Denmark.
| | - Søren Rud Kristensen
- Danish Centre for Health Economics, Department of Public Health, University of Southern Denmark, Campusvej 55, 5230 Odense M, Denmark.
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Brosig-Koch J, Hennig-Schmidt H, Kairies-Schwarz N, Kokot J, Wiesen D. A new look at physicians' responses to financial incentives: Quality of care, practice characteristics, and motivations. JOURNAL OF HEALTH ECONOMICS 2024; 94:102862. [PMID: 38401249 DOI: 10.1016/j.jhealeco.2024.102862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 01/26/2024] [Accepted: 01/31/2024] [Indexed: 02/26/2024]
Abstract
There is considerable controversy about what causes (in)effectiveness of physician performance pay in improving the quality of care. Using a behavioral experiment with German primary-care physicians, we study the incentive effect of performance pay on service provision and quality of care. To explore whether variations in quality are based on the incentive scheme and the interplay with physicians' real-world profit orientation and patient-regarding motivations, we link administrative data on practice characteristics and survey data on physicians' attitudes with experimental data. We find that, under performance pay, quality increases by about 7pp compared to baseline capitation. While the effect increases with the severity of illness, the bonus level does not significantly affect the quality of care. Data linkage indicates that primary-care physicians in high-profit practices provide a lower quality of care. Physicians' other-regarding motivations and attitudes are significant drivers of high treatment quality.
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Affiliation(s)
- Jeannette Brosig-Koch
- Otto von Guericke University Magdeburg and Health Economics Research Center (CINCH) Essen, Germany.
| | | | - Nadja Kairies-Schwarz
- Heinrich-Heine University Düsseldorf, Medical Faculty, Centre for Health and Society (chs) and German Diabetes Center, Leibniz Center for Diabetes Research, Germany.
| | - Johanna Kokot
- University of Hamburg and Hamburg Center for Health Economics, Germany.
| | - Daniel Wiesen
- University of Cologne, Department of Healthcare Management and Center for Social and Economic Behavior (C-SEB), Germany.
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14
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Kim S, Kim GO, Lee S, Kwon YU. Effects of intensive care unit quality assessment on changes in medical staff in medical institutions and in-hospital mortality. HUMAN RESOURCES FOR HEALTH 2024; 22:12. [PMID: 38308311 PMCID: PMC10835892 DOI: 10.1186/s12960-024-00893-1] [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: 07/26/2023] [Accepted: 01/16/2024] [Indexed: 02/04/2024]
Abstract
BACKGROUND Quality assessments are being introduced in many countries to improve the quality of care and maintain acceptable quality levels. In South Korea, various quality assessments are being conducted to improve the quality of care, but there is insufficient evidence on intensive care units (ICUs). This study aims to evaluate the impact of ICU quality assessments on the structural indicators in medical institutions and the resulting in-hospital mortality of patients. METHODS This study used data collected in the 2nd and 3rd ICU quality assessments in 2017 and 2019. A total of 72,879 patients admitted to ICUs were included during this period, with 265 institutions that received both assessments. As for structural indicators, changes in medical personnel and equipment were assessed, and in-hospital deaths were evaluated as patient outcomes. To evaluate the association between medical staff and in-hospital mortality, a generalized estimating equation model was performed considering both hospital and patient variables. RESULTS Compared to the second quality evaluation, the number of intensivist physicians and experienced nurses increased in the third quality evaluation; however, there was still a gap in the workforce depending on the type of medical institution. Among all ICU patients admitted during the evaluation period, 12.0% of patients died in the hospital. In-hospital mortality decreased at the 3rd assessment, and hospitals employing intensivist physicians were associated with reduced in-hospital deaths. In addition, an increase in the number of experienced nurses was associated with a decrease in in-hospital mortality, while an increase in the nurse-to-bed ratio increased mortality. CONCLUSIONS ICU quality assessments improved overall structural indicators, but the gap between medical institutions has not improved and interventions are required to bridge this gap. In addition, it is important to maintain skilled medical personnel to bring about better results for patients, and various efforts should be considered. This requires continuous monitoring and further research on long-term effects.
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Affiliation(s)
- Seungju Kim
- Department of Health System, College of Nursing, The Catholic University of Korea, 222, Banpo-Daero, Seocho-Gu, Seoul, 06591, Republic of Korea.
- Research Institute for Hospice/Palliative Care, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Gui Ok Kim
- Department of Quality Assessment, Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Syalrom Lee
- Department of Quality Assessment, Health Insurance Review and Assessment Service, Wonju, Republic of Korea
| | - Yong Uk Kwon
- Healthcare Review and Assessment CommitteeHealth Insurance Review and Assessment Service, Wonju, Republic of Korea
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15
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Prager E, Sinaiko AD. Tiered network health plans and changes in physician practice intensity. Health Serv Res 2024; 59:e14163. [PMID: 37127429 PMCID: PMC10771897 DOI: 10.1111/1475-6773.14163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVE To examine whether physicians in tiered physician networks where tier assignments are based on "intensity" of care, which is the quantity of resources used per-episode of care, change their intensity after learning detailed information about how their intensity compares to their peers. DATA SOURCES Administrative data on intensity and quality at the physician-episode level for all physicians included in a tiered physician network offered through the Massachusetts Group Insurance Commission (GIC) in 2010-2015. Data on physicians' share of revenue from GIC patients from the 2012 Massachusetts All-Payer Claims Database. STUDY DESIGN For 21,086 physicians in seven specialties, we estimate the impact of the dissemination of detailed intensity performance information in 2014 on physician intensity per episode of care overall and decomposed into physician services, facility, and pharmaceutical subcomponents. Intensity outcomes were measured using a standardized price schedule. Using a difference-in-differences regression, we compared physicians with high exposure to the tiered network via a large share of their revenue coming from GIC patients ("GIC share") to physicians who were less exposed. Measures of intensity of care and GIC share were log-transformed, and models controlled for physician-episode type fixed effects. DATA EXTRACTION METHODS We linked GIC share to administrative data using National Provider Identifier. PRINCIPAL FINDINGS There were no statistically significant differences in total intensity of care with the informational intervention for physicians in procedure-based specialties (-0.12 elasticity of intensity per episode with respect to GIC patient share, 95% CI -0.30 to 0.06) or in relationship-based specialties (0.09, 95% CI -0.15 to 0.33). There were also no differences in intensity of subcomponents of care following the intervention. CONCLUSIONS Tiered network incentives had no detectable impact on intensity of care that physicians provided to patients.
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Affiliation(s)
- Elena Prager
- Simon Business SchoolUniversity of RochesterRochesterNew YorkUSA
| | - Anna D. Sinaiko
- Department of Health Policy & ManagementHarvard T.H. Chan School of Public Health, Harvard UniversityBostonMassachusettsUSA
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16
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Psarras A, Karakolias S. A Groundbreaking Insight Into Primary Care Physiotherapists' Remuneration. Cureus 2024; 16:e54732. [PMID: 38523929 PMCID: PMC10961143 DOI: 10.7759/cureus.54732] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/22/2024] [Indexed: 03/26/2024] Open
Abstract
Introduction Physiotherapy in Greece, as part of primary health care (PHC), faces sound imbalances: reduced quality, productivity, and efficiency, along with rather inflexible remuneration schemes. This study is aimed at reporting the attitude and perceptions of Greek PHC physiotherapists toward their current remuneration and also at identifying any other preferable remuneration schemes. Methods A stratified proportional sampling study was undertaken, using an anonymous, electronic survey. The participants were 250 self-employed physiotherapists running their business in Central and Eastern Macedonia and Thrace, being also contracted with the National Organisation for Healthcare Provision (EOPYY). The sample size stands for 34% of the population with a circa 5% margin of error. Results Nearly 9/10 physiotherapists (84%) underline that remuneration falls short of their productivity, leading to reduced job satisfaction. Moreover, their remuneration does not motivate them to provide services of higher quality (46%), while 58% of them stated that they are forced to claim informal fees. There is no clear desire regarding the remuneration scheme, but nearly ¼ of physiotherapists revealed their preference for the cost-per-case philosophy combined with co-payments. Conclusion The majority of physiotherapists believe that their current remuneration does not reflect their productivity nor the quality of their services and, therefore, informal payments arise. The preference of physiotherapists lies between cost-per-case fees and patient co-payments, which, however, favors supplier-induced demand and access inequalities, respectively. Hence, policymakers should revise the current remuneration scheme and overcome its deficiencies without creating new ones.
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Affiliation(s)
| | - Stefanos Karakolias
- Department of Organisation Management, Marketing and Tourism, International Hellenic University, Thessaloniki, GRC
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17
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Garner BR, Tueller S, Bradshaw M, Speck K, Satre D, Rash C, Donohoe T, Mungo J, Philbrick S, Ruwala R, Roosa M, Zehner M, Ford J. Testing the incremental effectiveness of pay-for-performance to improve implementation of a motivational interviewing brief intervention for substance use disorders in HIV settings: Results of a cluster-randomized type 3 hybrid trial. RESEARCH SQUARE 2023:rs.3.rs-3685134. [PMID: 38196639 PMCID: PMC10775385 DOI: 10.21203/rs.3.rs-3685134/v1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2024]
Abstract
Background Substance use disorders (SUDs) have a serious adverse impact on people living with HIV. Previously, using a 39-site dual-randomized type 2 hybrid trial design, findings from the Substance Abuse Treatment to HIV Care Project supported the Implementation and Sustainment Facilitation (ISF) strategy to improve implementation and effectiveness of a motivational interviewing brief intervention (MIBI) for SUD within HIV service settings across the United States (US). Building on this trial, this cluster-randomized type 3 hybrid trial aimed to test the incremental effectiveness of a pay-for-performance (P4P), a form of the "alter incentive/allowance structures" strategy. Methods Twenty-six HIV service organizations, their staff participants (N=87), and their client participants (N=341) were cluster-randomized to one of two implementation conditions. The control condition included staff-focused training, feedback, and consultation (TFC) and team-focused implementation and sustainment (ISF). The experimental condition included TFC+ISF as well as P4P (TFC+ISF+P4P). P4P used financial incentives to reward MIBI implementation (US$10 per MIBI delivered) and MIBI implementation at or above a pre-defined level of quality (US$10 per demonstration). In addition to these outcomes, past 4-week changes/reductions in client participant's days of primary substance use and anxiety symptoms were examined. Results The addition of P4P had a large and significant effect on the number of MIBIs implemented (d=1.30, p<.05) and reduction in anxiety (d=-1.54), but there was no impact on days of substance use. P4P had large effects on MIBI quality (d=1.24) and MIBI implementation effectiveness (d=1.28), but these were not significant (p<.10). Conclusions P4P is a form of the "alter incentive/allowance structures" strategy Its function is to reward the implementation of a clinical innovation. Rewarding implementation is consistent with the theory of implementation effectiveness, which suggests implementation climate (i.e., the extent to which implementation is expected, supported, and rewarded) is a key antecedent of implementation effectiveness (i.e., the consistency and quality of implementation). We found that P4P had a significant, positive impact on MIBI implementation in HIV service settings, but client-level outcomes were mixed. Future research should examine the cost-effectiveness of this strategy, as well as to examine the effectiveness of P4P to improve the implementation of other evidence-based innovations. Trial registration ClinicalTrials.gov: NCT04687917. Registered 12/18/2020.
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Affiliation(s)
- Bryan R Garner
- The Ohio State University College of Medicine and Public Health: The Ohio State University College of Medicine
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Blue L, Kranker K, Markovitz AR, Powell RE, Williams MV, Pu J, Magid DJ, McCall N, Steiner A, Stewart KA, Rollison JM, Markovich P, Peterson GG. Effects of the Million Hearts Model on Myocardial Infarctions, Strokes, and Medicare Spending: A Randomized Clinical Trial. JAMA 2023; 330:1437-1447. [PMID: 37847273 PMCID: PMC10582785 DOI: 10.1001/jama.2023.19597] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 09/12/2023] [Indexed: 10/18/2023]
Abstract
Importance The Million Hearts Model paid health care organizations to assess and reduce cardiovascular disease (CVD) risk. Model effects on long-term outcomes are unknown. Objective To estimate model effects on first-time myocardial infarctions (MIs) and strokes and Medicare spending over a period up to 5 years. Design, Setting, and Participants This pragmatic cluster-randomized trial ran from 2017 to 2021, with organizations assigned to a model intervention group or standard care control group. Randomized organizations included 516 US-based primary care and specialty practices, health centers, and hospital-based outpatient clinics participating voluntarily. Of these organizations, 342 entered patients into the study population, which included Medicare fee-for-service beneficiaries aged 40 to 79 years with no previous MI or stroke and with high or medium CVD risk (a 10-year predicted probability of MI or stroke [ie, CVD risk score] ≥15%) in 2017-2018. Intervention Organizations agreed to perform guideline-concordant care, including routine CVD risk assessment and cardiovascular care management for high-risk patients. The Centers for Medicare & Medicaid Services paid organizations to calculate CVD risk scores for Medicare fee-for-service beneficiaries. CMS further rewarded organizations for reducing risk among high-risk beneficiaries (CVD risk score ≥30%). Main Outcomes and Measures Outcomes included first-time CVD events (MIs, strokes, and transient ischemic attacks) identified in Medicare claims, combined first-time CVD events from claims and CVD deaths (coronary heart disease or cerebrovascular disease deaths) identified using the National Death Index, and Medicare Parts A and B spending for CVD events and overall. Outcomes were measured through 2021. Results High- and medium-risk model intervention beneficiaries (n = 130 578) and standard care control beneficiaries (n = 88 286) were similar in age (median age, 72-73 y), sex (58%-59% men), race (7%-8% Black), and baseline CVD risk score (median, 24%). The probability of a first-time CVD event within 5 years was 0.3 percentage points lower for intervention beneficiaries than control beneficiaries (3.3% relative effect; adjusted hazard ratio [HR], 0.97 [90% CI, 0.93-1.00]; P = .09). The 5-year probability of combined first-time CVD events and CVD deaths was 0.4 percentage points lower in the intervention group (4.2% relative effect; HR, 0.96 [90% CI, 0.93-0.99]; P = .02). Medicare spending for CVD events was similar between the groups (effect estimate, -$1.83 per beneficiary per month [90% CI, -$3.97 to -$0.30]; P = .16), as was overall Medicare spending including model payments (effect estimate, $2.11 per beneficiary per month [90% CI, -$16.66 to $20.89]; P = .85). Conclusions and Relevance The Million Hearts Model, which encouraged and paid for CVD risk assessment and reduction, reduced first-time MIs and strokes. Results support guidelines to use risk scores for CVD primary prevention. Trial Registration ClinicalTrials.gov Identifier: NCT04047147.
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Affiliation(s)
| | | | | | - Rhea E. Powell
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Jia Pu
- Mathematica, Oakland, California
| | | | | | | | | | | | - Patricia Markovich
- Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland
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Chen CC, Chien KL, Cheng SH. Examining the Long-term Spillover Effects of a Pay-for-Performance Program in a Healthcare System That Lacks Referral Arrangements. Int J Health Policy Manag 2023; 12:7571. [PMID: 38618790 PMCID: PMC10699817 DOI: 10.34172/ijhpm.2023.7571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 08/30/2023] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Several studies have examined the intended effects of pay-for-performance (P4P) programs, yet little is known about the unintended spillover effects of such programs on intermediate clinical outcomes. This study examines the long-term spillover effects of a P4P program for diabetes care. METHODS This study uses a nationwide population-based natural experimental design with a 3-year follow-up period under Taiwan's universal coverage healthcare system. The intervention group consisted of 7688 patients who enrolled in the P4P program for diabetes care in 2017 and continuously participated in the program for three years. The comparison group was selected by propensity score matching (PSM) from patients seen by the same group of physicians. Each patient had four records: one pertaining to one year before the index date of the P4P program and the other three pertaining to follow-ups spanning over the next three years. Generalized estimating equations (GEEs) with difference-in-differences (DID) estimations were used to consider the correlation between repeated observations for the same patients and patients within the same matched pairs. RESULTS Patients enrolled in the P4P program showed improvements in incentivized intermediate clinical outcomes that persisted over three years, including proper control of glycated hemoglobin (HbA1c) and low-density lipoprotein cholesterol (LDL-C). We found a slight positive spillover effect of the P4P program on the control of non-incentivized triglyceride [TG]). However, we found no such effects on the non-incentivized high-density lipoprotein cholesterol (HDL-C) control. CONCLUSION The P4P program has achieved its primary goal of improving the incentivized intermediate clinical outcomes. The commonality in production among a set of activities is crucial for generating the spillover effects of an incentive program.
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Affiliation(s)
- Chi-Chen Chen
- Department of Public Health, College of Medicine, Fu-Jen Catholic University, Taipei, Taiwan
| | - Kuo-Liong Chien
- Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei, Taiwan
- Department of Internal Medicine, National Taiwan University, Taipei, Taiwan
- Population Health Research Center, National Taiwan University, Taipei, Taiwan
| | - Shou-Hsia Cheng
- Population Health Research Center, National Taiwan University, Taipei, Taiwan
- Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
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Leao DLL, Cremers HP, van Veghel D, Pavlova M, Hafkamp FJ, Groot WNJ. Facilitating and Inhibiting Factors in the Design, Implementation, and Applicability of Value-Based Payment Models: A Systematic Literature Review. Med Care Res Rev 2023; 80:467-483. [PMID: 36951451 PMCID: PMC10469482 DOI: 10.1177/10775587231160920] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/08/2023] [Indexed: 03/24/2023]
Abstract
Evidence on the potential for value-based payment models to improve quality of care and ensure more efficient outcomes is limited and mixed. We aim to identify the factors that enhance or inhibit the design, implementation, and application of these models through a systematic literature review. We used the PRISMA guidelines. The facilitating and inhibiting factors were divided into subcategories according to a theoretical framework. We included 143 publications, each reporting multiple factors. Facilitators on objectives and strategies, such as realistic/achievable targets, are reported in 56 studies. Barriers regarding dedicated time and resources (e.g., an excessive amount of time for improvements to manifest) are reported in 25 studies. Consensus within the network regarding objectives and strategies, trust, and good coordination is essential. Health care staff needs to be kept motivated, well-informed, and actively involved. In addition, stakeholders should manage expectations regarding when results are expected to be achieved.
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21
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Shams L, Zamani Fard M, Nasiri T, Mohammadshahi M. Community health workers (Behvarz) in primary health care: a qualitative inductive content analysis of challenges. Aust J Prim Health 2023; 29:428-436. [PMID: 36872455 DOI: 10.1071/py22052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 02/12/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Behvarzs are the backbone of primary healthcare services in the Iranian health system and play a key role in providing efficient, responsive, and equitable services at the first level of service provision. This study aimed to identify the challenges of Behvarzs to provide a perspective for policymakers and managers to help them formulate future programs to enhance the efficiency of the health system. METHODS Following a qualitative design, an inductive content analysis approach was used to analyse the data. The healthcare network of the Alborz province (Iran) was considered as the study context. A total of 27 interviews were conducted with policymakers, development managers, managers of Behavrz training centres, and Behvarz workers in 2020. All interviews were audio-taped and transcribed, followed by data analysis using MAXQDA ver. 10. RESULTS Five themes were identified: service provision (scope of services, ambiguity of roles, non-compliance with the referral system, the quality of data entry, quality of services), access to equipment (quantity, quality), administrative issues (macro planning, micro planning), training (appropriateness of information, quality of training, recruiting related staff), perceived equity and fairness (balance between workload, income, and benefits, job satisfaction, job promotion). CONCLUSION Occupational challenges affect the performance of Behvarzs in responding to society's needs because they not only play a major role in the health system, but also contribute to addressing the communication gap between local communities and high-level institutions, leading to the alignment of policy implementation. Therefore, strategies that emphasise the role of Behvarzs should be followed to promote community engagement.
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Affiliation(s)
- Lida Shams
- Department of Health Management, Policy and Economic, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Maryam Zamani Fard
- Department of Community Health Education, Virtual School of Medical Education and Management, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Taha Nasiri
- Department of Health Services Management, Faculty of Health, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Marita Mohammadshahi
- Health Economics, National Institute for Health Research, Tehran University of Medical Sciences, Tehran, Iran
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22
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Englert CH, Hammert WC. Older Patients Demonstrate PROMIS Outcomes Comparable to Younger Cohorts After Carpal Tunnel Release. Hand (N Y) 2023; 18:970-977. [PMID: 35179071 PMCID: PMC10470247 DOI: 10.1177/15589447211073828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The utility of Patient-Reported Outcomes Measurement Information System (PROMIS) in monitoring clinical progress after carpal tunnel release (CTR) in patients of different ages remains unknown. We sought to evaluate early PROMIS scores in elderly patients (ie, those aged ≥65 years) after CTR and compare those with all younger patients after CTR. METHODS Patients presenting to a single academic medical center for CTR between September 2018 and January 2020 completed PROMIS physical function (PF), pain interference (PI), and upper extremity (UE) computer adaptive tests and answered a single 5-point Likert-scale question evaluating subjective changes in their condition following CTR. Patients were divided into 3 age groups, and preoperative and postoperative PROMIS scores were compared. RESULTS In all, 214 patients fit inclusion criteria: 86 aged 18-54 years, 71 aged 55-64 years, and 57 aged ≥65 years. Subjective improvement was reported in 70.9% (n = 61), 84.5% (n = 60), and 71.9% (n = 41) of patients aged ≤54, 55-64, and ≥65 years, respectively. Patients aged ≤54 years showed significantly worse UE scores (P = .02), whereas those aged 55-64 years demonstrated significant worsening in all 3 PROMIS domains (P < .01). Patients aged ≥65 years who reported subjective improvement after CTR demonstrated significant improvement in PI scores (P = .03), whereas significant worsening of all PROMIS scores was observed in the subset of patients aged 55-64 years who reported subjective improvement (P < .01, .04, and .04 for PF, PI, and UE, respectively). CONCLUSIONS Younger patients showed worsening in PROMIS scores after CTR, whereas elderly patients did not show similar magnitude reductions in PROMIS scores. Moreover, the subset of elderly patients endorsing subjective improvement after CTR had reduced PI scores, consistent with less postoperative pain limitations.
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Yordanov D, Oxholm AS, Gyrd-Hansen D, Pedersen LB. Mapping GPs' motivation — it's not all about the money: a nationwide cross-sectional survey study from Denmark. Br J Gen Pract 2023; 73:e687-e693. [PMID: 37549995 PMCID: PMC10428006 DOI: 10.3399/bjgp.2022.0563] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 04/21/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND Understanding physicians' motivation may be essential for policymakers if they are to design policies that cater to physicians' wellbeing, job retention, and quality of care. However, physicians' motivation remains an understudied area. AIM To map GPs' work motivation. DESIGN AND SETTING A cross-sectional analysis using registry and survey data from Denmark. METHOD Survey data were used to measure four types of motivation: extrinsic motivation, intrinsic motivation, user orientation, and public service motivation. These were combined with register data on the characteristics of the GP, practice, and area. Using latent profile analysis, the heterogeneity in GPs' motivation was explored; the associations between GPs' motivation and the GP, practice, and area characteristics were estimated using linear regression analyses. RESULTS There was substantial heterogeneity in GPs' motivations. Five classes of GPs were identified with different work motivations: class 1 'it is less about the money' - probability of class membership 53.2%; class 2 'it is about everything' - 26.5%; class 3 'it is about helping others' - 8.6%; class 4 'it is about the work' - 8.2%; and class 5 'it is about the money and the patient' - 3.5%. Linear regression analyses showed that motivation was associated with GP, practice, and area characteristics to a limited extent only. CONCLUSION GPs differ in their work motivations. The finding that, for many GPs, 'it is not all about the money' indicated that their different motivations should be considered when designing new policies and organisational structures to retain the workforce and ensure a high quality of care.
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Affiliation(s)
- Dimitar Yordanov
- Danish Centre for Health Economics, University of Southern Denmark
| | | | | | - Line Bjørnskov Pedersen
- Danish Centre for Health Economics and Research Unit for General Practice, University of Southern Denmark, Odense
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Tummalapalli SL, Struthers SA, White DL, Beckrich A, Brahmbhatt Y, Erickson KF, Garimella PS, Gould ER, Gupta N, Lentine KL, Lew SQ, Liu F, Mohan S, Somers M, Weiner DE, Bieber SD, Mendu ML. Optimal Care for Kidney Health: Development of a Merit-based Incentive Payment System (MIPS) Value Pathway. J Am Soc Nephrol 2023; 34:1315-1328. [PMID: 37400103 PMCID: PMC10400097 DOI: 10.1681/asn.0000000000000163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 05/17/2023] [Indexed: 07/05/2023] Open
Abstract
The Merit-based Incentive Payment System (MIPS) is a mandatory pay-for-performance program through the Centers for Medicare & Medicaid Services (CMS) that aims to incentivize high-quality care, promote continuous improvement, facilitate electronic exchange of information, and lower health care costs. Previous research has highlighted several limitations of the MIPS program in assessing nephrology care delivery, including administrative complexity, limited relevance to nephrology care, and inability to compare performance across nephrology practices, emphasizing the need for a more valid and meaningful quality assessment program. This article details the iterative consensus-building process used by the American Society of Nephrology Quality Committee from May 2020 to July 2022 to develop the Optimal Care for Kidney Health MIPS Value Pathway (MVP). Two rounds of ranked-choice voting among Quality Committee members were used to select among nine quality metrics, 43 improvement activities, and three cost measures considered for inclusion in the MVP. Measure selection was iteratively refined in collaboration with the CMS MVP Development Team, and new MIPS measures were submitted through CMS's Measures Under Consideration process. The Optimal Care for Kidney Health MVP was published in the 2023 Medicare Physician Fee Schedule Final Rule and includes measures related to angiotensin-converting enzyme inhibitor and angiotensin receptor blocker use, hypertension control, readmissions, acute kidney injury requiring dialysis, and advance care planning. The nephrology MVP aims to streamline measure selection in MIPS and serves as a case study of collaborative policymaking between a subspecialty professional organization and national regulatory agencies.
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Affiliation(s)
- Sri Lekha Tummalapalli
- Division of Healthcare Delivery Science & Innovation and Division of Nephrology & Hypertension, Weill Cornell Medicine, New York, New York
- The Rogosin Institute, New York, New York
| | - Sarah A. Struthers
- Division of Nephrology, Department of Medicine, University of Washington, Seattle, Washington
| | | | - Amy Beckrich
- Renal Physicians Association, Rockville, Maryland
| | | | - Kevin F. Erickson
- Selzman Institute for Kidney Health, Section of Nephrology, Baylor College of Medicine, Houston, Texas
| | - Pranav S. Garimella
- Division of Nephrology-Hypertension, University of California San Diego, San Diego, California
| | - Edward R. Gould
- Division of Nephrology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Nupur Gupta
- Division of Nephrology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Krista L. Lentine
- Saint Louis University Transplant Center, SSM-Saint Louis University Hopstial, St. Louis, Missouri
| | - Susie Q. Lew
- Division of Renal Diseases and Hypertension, George Washington University, Washington, DC
| | - Frank Liu
- The Rogosin Institute, New York, New York
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Vagelos College of Physicians & Surgeons, Columbia University, New York, New York
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, New York
| | - Michael Somers
- Division of Nephrology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Daniel E. Weiner
- Division of Nephrology, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | | | - Mallika L. Mendu
- Division of Renal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston Massachusetts
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Nkangu M, Little J, Deonandan R, Pongou R, Yaya S. An in-depth qualitative study of health care providers' experiences of performance-based financing program as a nation-wide adopted policy in Cameroon: A principal-agent perspective. PLoS One 2023; 18:e0288767. [PMID: 37506076 PMCID: PMC10381064 DOI: 10.1371/journal.pone.0288767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 07/04/2023] [Indexed: 07/30/2023] Open
Abstract
OBJECTIVES The study applies the principal-agent approach to explore providers' experiences before and after the introduction of performance-based financing (PBF) in Cameroon, challenges and facilitators in the implementation process, and mechanisms in place to ensure sustainability. METHODS The study was an in-depth qualitative study whose goal was to provide multiple descriptions of experiences and insights from a principal-agent analysis perspective. Purposive sampling was used to identify the key characteristics of the participants relevant to the study. A snowballing technique was used to further identify eligible participants. Only healthcare providers who were exposed to the previous system and could reflect on and provide meaningful data that captured the everyday experiences before and after the implementation of PBF were included. Data were collected from three districts in the Southwest region of Cameroon from May 2021 to August 2021. Data were transcribed and analyzed using MaxQDA. RESULTS A total of 17 interviews and 3 focus group discussions (24 participants) were conducted with healthcare providers and key stakeholders involved in PBF. The respondents described a range of changes that they had experienced since the introduction of PBF. Each of these changes was categorized as either positive or negative. Positive changes were framed into 14 dominant categories: motivation, negotiations, innovation, resource allocation, autonomy, decentralization, transparency, improved quality of care, separation of function, performance, equity considerations, opportunity to recruit, participation in decision-making, and improved access to and utilization of maternal health services. The main challenges (negative experiences) reported were framed into nine categories: management of change, retention issues, conflict of interest, poor understanding of the PBF concept, resistance to change, verification challenges, delays in payment of PBF incentives, data entry and documentation, and challenges in meeting the equity considerations of the poor and vulnerable. Despite the challenges, providers preferred the decentralized approach to the centralized system. CONCLUSION PBF is a national strategy for achieving universal health coverage in Cameroon, and the experiences of providers provide a vital guide to refine national policy. The introduction of PBF has provided positive changes to providers' quality of care when compared to the previous system. Addressing the delays in PBF payments will help to overcome the challenges to implementation and provide opportunities for health facilities to be more efficient and improve their performance. Despite the limitations of delay in payment, PBF helps to align the incentives of the health workers (agent) with those of the Ministry of Health (principal).
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Affiliation(s)
- Miriam Nkangu
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
- Health Promotion Alliance Cameroon (HPAC), Yaounde, Cameroon
| | - Julian Little
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Raywat Deonandan
- Interdisciplinary School of Health Sciences, University of Ottawa, Ottawa, Canada
| | - Roland Pongou
- Department of Economics, University of Ottawa, Ottawa, Canada
| | - Sanni Yaya
- School of International Development and Global Studies, University of Ottawa, Ottawa, Canada
- The George Institute for Global Health, Imperial College London, London, United Kingdom
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26
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Carter HE, Allen MJ, Toohey LA, McPhail SM, Drew MK. Alternative Reimbursement Models for Health Providers in High-Performance Sport: Stakeholder Experiences and Perceptions. SPORTS MEDICINE - OPEN 2023; 9:53. [PMID: 37432643 DOI: 10.1186/s40798-023-00600-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/19/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Value-based healthcare provider reimbursement models have been proposed as an alternative to traditional fee-for-service arrangements that can align financial reimbursement more closely to the outcomes of value to patients and society. This study aimed to investigate stakeholder perceptions and experiences of different reimbursement systems for healthcare providers in high-performance sport, with a focus on fee-for-service versus salaried provider models. METHODS Three in-depth semi-structured focus group discussions and one individual interview were conducted with key stakeholders across the Australian high-performance sport system. Participants included healthcare providers, health managers, sports managers and executive personnel. An interview guide was developed using the Exploration, Preparation, Implementation, Sustainment framework, with key themes deductively mapped to the innovation, inner context and outer context domains. A total of 16 stakeholders participated in a focus group discussion or interview. RESULTS Participants identified several key advantages of salaried provider models over fee-for-service arrangements, including: the potential for more proactive and preventive models of care; enhanced inter-disciplinary collaboration; and the ability for providers to have a deeper understanding of context and how their role aligns with a broader set of priorities for an athlete and the organisation. Noted challenges of salaried provider models included the potential for providers to revert to reactive care delivery when not afforded adequate capacity to provide services, and difficulties for providers in demonstrating and quantifying the value of their work. CONCLUSIONS Our findings suggest that high-performance sporting organisations seeking to improve primary prevention and multidisciplinary care should consider salaried provider arrangements. Further research to confirm these findings using prospective, experimental study designs remains a priority.
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Affiliation(s)
- Hannah E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Faculty of Health, School of Public Health and Social Work, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia.
| | - Michelle J Allen
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Faculty of Health, School of Public Health and Social Work, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia
| | - Liam A Toohey
- Athlete Performance Health, Australian Institute of Sport, Canberra, Australia
- University of Canberra Research Institute for Sport and Exercise (UCRISE), Canberra, Australia
| | - Steven M McPhail
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, Faculty of Health, School of Public Health and Social Work, Queensland University of Technology, 60 Musk Ave, Kelvin Grove, QLD, 4059, Australia
- Digital Health and Informatics Directorate, Metro South Health, Brisbane, Australia
| | - Michael K Drew
- University of Canberra Research Institute for Sport and Exercise (UCRISE), Canberra, Australia
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Anselmi L, Ohrnberger J, Fichera E, Nhassengo P, Fernandes QF, Chicumbe S. The impact of performance-based financing within local health systems: Evidence from Mozambique. HEALTH ECONOMICS 2023; 32:1525-1549. [PMID: 36973224 PMCID: PMC10947248 DOI: 10.1002/hec.4677] [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: 02/28/2021] [Revised: 02/24/2023] [Accepted: 02/28/2023] [Indexed: 06/04/2023]
Abstract
Most evidence on Performance Based Financing (PBF) in low-income settings has focused on services delivered by providers in targeted health administrations, with limited understanding of how effects on health and care vary within them. We evaluated the population effects of a program implemented in two provinces in Mozambique, focusing on child, maternal and HIV/AIDS care and knowledge. We used a difference-in-difference estimation strategy applied to data on mothers from the Demographic Health Surveys, linked to information on their closest health facility. The impact of PBF was limited. HIV testing during antenatal care increased, particularly for women who were wealthier, more educated, or residing in Gaza Province. Knowledge about transmission of HIV from mother-to-child, and its prevention, increased, particularly for women who were less wealthy, less educated, or residing in Nampula Province. Exploiting the roll-out by facility, we found that the effects were concentrated on less wealthy and less educated women, whose closest facility was in the referral network of a PBF facility. Results suggest that HIV testing and knowledge promotion increased in the whole district, as a strategy to boost referral for highly incentivized HIV services delivered in PBF facilities. However, demand-side constraints may prevent the use of those services.
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Affiliation(s)
- Laura Anselmi
- Division of Population HealthHealth Services Research & Primary CareUniversity of ManchesterManchesterUK
| | - Julius Ohrnberger
- School of Public HealthMRC Centre for Global Infectious Disease AnalysisImperial College LondonLondonUK
| | | | | | - Quinhas F. Fernandes
- Department of Global HealthUniversity of WashingtonWashingtonSeattleUSA
- Direção Nacional de Saúde Publica, Ministério da SaúdeMaputoMozambique
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Britteon P, Kristensen SR, Lau YS, McDonald R, Sutton M. Spillover effects of financial incentives for providers onto non-targeted patients: daycase surgery in English hospitals. HEALTH ECONOMICS, POLICY, AND LAW 2023; 18:289-304. [PMID: 37190849 DOI: 10.1017/s1744133123000063] [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] [Indexed: 05/17/2023]
Abstract
BACKGROUND Incentives for healthcare providers may also affect non-targeted patients. These spillover effects have important implications for the full impact and evaluation of incentive schemes. However, there are few studies on the extent of such spillovers in health care. We investigated whether incentives to perform surgical procedures as daycases affected whether other elective procedures in the same specialties were also treated as daycases. DATA 8,505,754 patients treated for 92 non-targeted procedures in 127 hospital trusts in England between April and March 2016. METHODS Interrupted time series analysis of the probability of being treated as a daycase for non-targeted patients treated in six specialties where targeted patients were also treated and three specialties where they were not. RESULTS The daycase rate initially increased (1.04 percentage points, SE: 0.30) for patients undergoing a non-targeted procedure in incentivised specialties but then reduced over time. Conversely, the daycase rate gradually decreased over time for patients treated in a non-incentivised specialty. DISCUSSION Spillovers from financial incentives have variable effects over different activities and over time. Policymakers and researchers should consider the possibility of spillovers in the design and evaluation of incentive schemes.
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Affiliation(s)
- Philip Britteon
- Health Organisation, Policy and Economics, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Søren Rud Kristensen
- Health Organisation, Policy and Economics, School of Health Sciences, The University of Manchester, Manchester, UK
- Danish Centre for Health Economics, University of Southern Denmark, Odense, Denmark
| | - Yiu-Shing Lau
- Health Organisation, Policy and Economics, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Ruth McDonald
- Alliance Manchester Business School, The University of Manchester, Manchester, UK
| | - Matt Sutton
- Health Organisation, Policy and Economics, School of Health Sciences, The University of Manchester, Manchester, UK
- Melbourne Institute: Applied Economics and Social Research, University of Melbourne, Melbourne, Australia
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Lu JFR, Chen YI, Eggleston K, Chen CH, Chen B. Assessing Taiwan's pay-for-performance program for diabetes care: a cost-benefit net value approach. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:717-733. [PMID: 35995886 DOI: 10.1007/s10198-022-01504-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 07/26/2022] [Indexed: 05/20/2023]
Abstract
Pay-for-Performance (P4P) to better manage chronic conditions has yielded mixed results. A better understanding of the cost and benefit of P4P is needed to improve program assessment. To this end, we assessed the effect of a P4P program using a quasi-experimental intervention and control design. Two different intervention groups were used, one consisting of newly enrolled P4P patients, and another using P4P patients who have been enrolled since the beginning of the study. Patient-level data on clinical indicators, utilization and expenditures, linked with national death registry, were collected for diabetic patients at a large regional hospital in Taiwan between 2007 and 2013. Net value, defined as the value of life years gained minus the cost of care, is calculated and compared for the intervention group of P4P patients with propensity score-matched non-P4P samples. We found that Taiwan's implementation of the P4P program for diabetic care yielded positive net values, ranging from $40,084 USD to $348,717 USD, with higher net values in the continuous enrollment model. Our results suggest that the health benefits from P4P enrollment may require a sufficient time frame to manifest, so a net value approach incorporating future predicted mortality risks may be especially important for studying chronic disease management. Future research on the mechanisms by which the Taiwan P4P program helped improve outcomes could help translate our findings to other clinical contexts.
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Affiliation(s)
- Jui-Fen Rachel Lu
- Graduate Institute of Business and Management and Department of Health Care Management, College of Management, Chang Gung University, Taoyuan City, Taiwan
- Department of Radiation Oncology, Chang Gung Memorial Hospital in Linkou, Taoyuan City, Taiwan
| | - Ying Isabel Chen
- Graduate Institute of Epidemiology and Preventive Medicine, College of Public Health, National Taiwan University, Taipei City, Taiwan
| | - Karen Eggleston
- Shorenstein Asia-Pacific Research Center, Freeman Spogli Institute for International Studies, Stanford University, and NBER, Stanford, CA, USA
| | - Chih-Hung Chen
- Division of Metabolism, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Brian Chen
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC, USA.
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Farcher R, Graber SM, Thüring N, Blozik E, Huber CA. Does the implementation of an incentive scheme increase adherence to diabetes guidelines? A retrospective cohort study of managed care enrollees. BMC Health Serv Res 2023; 23:707. [PMID: 37386491 PMCID: PMC10308744 DOI: 10.1186/s12913-023-09694-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 06/13/2023] [Indexed: 07/01/2023] Open
Abstract
BACKGROUND A novel incentive scheme based on a joint agreement of a large Swiss health insurance with 56 physician networks was implemented in 2018. This study evaluated the effect of its implementation on adherence to evidence-based guidelines among patients with diabetes in managed care models. METHODS We performed a retrospective cohort study, using health care claims data from patients with diabetes enrolled in a managed care plan (2016-2019). Guideline adherence was assessed by four evidence-based performance measures and four hierarchically constructed adherence levels. Generalized multilevel models were used to examine the effect of the incentive scheme on guideline adherence. RESULTS A total of 6'273 patients with diabetes were included in this study. The raw descriptive statistics showed minor improvements in guideline adherence after the implementation. After adjusting for underlying patient characteristics and potential differences between physician networks, the likelihood of receiving a test was moderately but consistently higher after the implementation of the incentive scheme for most performance measures, ranging from 18% (albuminuria: OR, 1.18; 95%-CI, 1.05-1.33) to 58% (HDL cholesterol: OR, 1.58; 95%-CI, 1.40-1.78). Full adherence was more likely after implementation of the incentive scheme (OR, 1.37; 95%-CI, 1.20-1.55), whereas level 1 significantly decreased (OR, 0.74; 95%-CI, 0.65 - 0.85). The proportions of the other adherence levels were stable. CONCLUSION Incentive schemes including transparency of the achieved performance may be able to improve guideline adherence in patients with diabetes and are promising to increase quality of care in this patient population.
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Affiliation(s)
- Renato Farcher
- Department of Health Sciences, Helsana Group, P.O. Box, Zürich, Switzerland
| | - Sereina M. Graber
- Department of Health Sciences, Helsana Group, P.O. Box, Zürich, Switzerland
| | - Nicole Thüring
- Department of Managed Care, Helsana Group, P.O. Box, Zürich, Switzerland
| | - Eva Blozik
- Institute of Primary Care, University of Zürich, University Hospital Zürich, Zürich, Switzerland
| | - Carola A. Huber
- Department of Health Sciences, Helsana Group, P.O. Box, Zürich, Switzerland
- Institute of Primary Care, University of Zürich, University Hospital Zürich, Zürich, Switzerland
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Pandey A, Eastman D, Hsu H, Kerrissey MJ, Rosenthal MB, Chien AT. Value-Based Purchasing Design And Effect: A Systematic Review And Analysis. Health Aff (Millwood) 2023; 42:813-821. [PMID: 37276480 PMCID: PMC11026120 DOI: 10.1377/hlthaff.2022.01455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
During the past two decades in the United States, all major payer types-commercial, Medicare, Medicaid, and multipayer coalitions-have introduced value-based purchasing (VBP) contracts to reward providers for improving health care quality while reducing spending. This systematic review qualitatively characterized the financial and nonfinancial features of VBP programs and examined how such features combine to create a level of program intensity that relates to desired quality and spending outcomes. Higher-intensity VBP programs are more frequently associated with desired quality processes, utilization measures, and spending reductions than lower-intensity programs. Thus, although there may be reasons for payers and providers to opt for lower-intensity programs (for example, to increase voluntary participation), these choices apparently have consequences for spending and quality outcomes.
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Affiliation(s)
| | | | - Heather Hsu
- Heather Hsu, Boston University, Boston, Massachusetts
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Decker KL, Schwab SD, Bazzoli GJ, Chukmaitov AS, Wernz C. Impact of performance-based budgeting on quality outcomes in U.S. military health care facilities. Health Care Manage Rev 2023; 48:249-259. [PMID: 37170408 DOI: 10.1097/hmr.0000000000000372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
BACKGROUND Performance-based budgeting (PBB) is a variation of pay for performance that has been used in government hospitals but could be applicable to any integrated system. It works by increasing or decreasing funding based on preestablished performance thresholds, which incentivizes organizations to improve performance. In late 2006, the U.S. Army implemented a PBB program that tied hospital-level funding decisions to performance on key cost and quality-related metrics. PURPOSE The aim of this study was to estimate the impact of PBB on quality improvement in U.S. Army health care facilities. APPROACH This study used a retrospective difference-in-differences analysis of data from two Defense Health Agency data repositories. The merged data set encompassed administrative, demographic, and performance information about 428 military health care facilities. Facility-level performance data on quality indicators were compared between 187 Army PBB facilities and a comparison group of 241 non-PBB Navy and Air Force facilities before and after program implementation. RESULTS The Army's PBB programs had a positive impact on quality performance. Relative to comparison facilities, facilities that participated in PBB programs increased performance for over half of the indicators under investigation. Furthermore, performance was either sustained or continued to improve over 5 years for five of the six performance indicators examined long term. CONCLUSION Study findings indicate that PBB may be an effective policy mechanism for improving facility-level performance on quality indicators. PRACTICE IMPLICATIONS This study adds to the extant literature on pay for performance by examining the specific case of PBB. It demonstrates that quality performance can be influenced internally through centralized budgeting processes. Though specific to military hospitals, the findings might have applicability to other public and private sector hospitals who wish to incentivize performance internally in their organizational subunits through centralized budgeting processes.
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Roseleur J, Gonzalez-Chica DA, Harvey G, Stocks NP, Karnon J. The Cost of Uncontrolled Blood Pressure in Australian General Practice: A Modelling Study Using Electronic Health Records (MedicineInsight). PHARMACOECONOMICS 2023; 41:573-587. [PMID: 36870035 PMCID: PMC9985098 DOI: 10.1007/s40273-023-01251-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/09/2023] [Indexed: 05/10/2023]
Abstract
BACKGROUND Hypertension is the most common condition seen in Australian general practice. Despite hypertension being amenable to lifestyle modifications and pharmacological treatment, only around half of these patients have controlled blood pressure levels (< 140/90 mmHg), placing them at an increased risk of cardiovascular disease. OBJECTIVE We aimed to estimate the health and acute hospitalisation costs of uncontrolled hypertension among patients attending general practice. METHODS We used population data and electronic health records from 634,000 patients aged 45-74 years who regularly attended an Australian general practice between 2016 and 2018 (MedicineInsight database). An existing worksheet-based costing model was adapted to calculate the potential cost savings for acute hospitalisation of primary cardiovascular disease events by reducing the risk of a cardiovascular event over the next 5 years through improved systolic blood pressure control. The model estimated the number of expected cardiovascular disease events and associated acute hospital costs under current levels of systolic blood pressure and compared this estimate with the expected number of cardiovascular disease events and costs under different levels of systolic blood pressure control. RESULTS The model estimated that across all Australians aged 45-74 years who visit their general practitioner (n = 8.67 million), 261,858 cardiovascular disease events can be expected over the next 5 years at current systolic blood pressure levels (mean 137.8 mmHg, standard deviation = 12.3 mmHg), with a cost of AUD$1813 million (in 2019-20). By reducing the systolic blood pressure of all patients with a systolic blood pressure greater than 139 mmHg to 139 mmHg, 25,845 cardiovascular disease events could be avoided with an associated reduction in acute hospital costs of AUD$179 million. If systolic blood pressure is lowered further to 129 mmHg for all those with systolic blood pressure greater than 129 mmHg, 56,169 cardiovascular disease events could be avoided with potential cost savings of AUD$389 million. Sensitivity analyses indicate that potential cost savings range from AUD$46 million to AUD$1406 million and AUD$117 million to AUD$2009 million for the two scenarios, respectively. Cost savings by practice range from AUD$16,479 for small practices to AUD$82,493 for large practices. CONCLUSIONS The aggregate cost effects of poor blood pressure control in primary care are high, but cost implications at the individual practice level are modest. The potential cost savings improve the potential to design cost-effective interventions, but such interventions may be best targeted at a population level rather than at individual practices.
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Affiliation(s)
- Jacqueline Roseleur
- School of Public Health, Faculty of Health Sciences, The University of Adelaide, Adelaide, SA, Australia.
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia.
- Flinders Health and Medical Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia.
| | - David A Gonzalez-Chica
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
- Adelaide Rural Clinical School, The University of Adelaide, Adelaide, SA, Australia
| | - Gillian Harvey
- Caring Futures Institute, College of Nursing and Health Sciences, Flinders University, Adelaide, SA, Australia
| | - Nigel P Stocks
- Discipline of General Practice, Adelaide Medical School, University of Adelaide, Adelaide, SA, Australia
| | - Jonathan Karnon
- Flinders Health and Medical Institute, College of Medicine and Public Health, Flinders University, Adelaide, SA, Australia
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Leao DLL, Cremers HP, van Veghel D, Pavlova M, Groot W. The Impact of Value-Based Payment Models for Networks of Care and Transmural Care: A Systematic Literature Review. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:441-466. [PMID: 36723777 PMCID: PMC10119264 DOI: 10.1007/s40258-023-00790-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 01/05/2023] [Indexed: 05/03/2023]
Abstract
INTRODUCTION Value-based healthcare has potential for cost control and quality improvement. To assess this, we review the evidence on the impact of value-based payment (VBP) models in the context of networks of care (NOC) and transmural care. METHODS We used the PRISMA guidelines for this systematic literature review. We searched eight databases in July 2021. Subsequently, we conducted title and abstract and full-text screenings, and extracted information in an extraction matrix. Based on this, we assessed the evidence on the effects of VBP models on clinical outcomes, patient-reported outcomes/experiences, organization-related outcomes/experiences, and costs. Additionally, we reviewed the facilitating and inhibiting factors per VBP model. FINDINGS Among articles studying shared savings and pay-for-performance models, most outline positive effects on both clinical and cost outcomes, such as preventable hospitalizations and total expenditures, respectively. Most studies show no change in patient satisfaction and access to care when adopting VBP models. Providers' opinions towards the models are frequently negative. Transparency and communication among involved stakeholders are found to be key facilitating factors, transversal to all models. Additionally, a lack of trust is an inhibitor found in all VBP models, together with inadequate targets and insufficient incentives. In bundled payment and pay-for-performance models, complexity in the structure of the program and lack of experience in implementing required mechanisms are key inhibitors. CONCLUSIONS The overall positive effect on clinical and cost outcomes validates the success of VBP models. The mostly negative effects on organization-reported outcomes/experiences are corroborated by findings regarding providers' lack of awareness, trust, and engagement with the model. This may be justified by their exclusion from the design of the models, decreasing their sense of ownership and, therefore, motivation. Incentives, targets, benchmarks, and quality measures, if adequately designed, seem to be important facilitators, and if lacking or inadequate, they are key inhibitors. These are prominent facilitators and inhibitors for P4P and shared savings models but not as prominent for bundled payments. The complexity of the scheme and lack of experience are prominent inhibitors in all VBP models, since all require changes in several areas, such as behavioral, process, and infrastructure.
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Affiliation(s)
- Diogo L L Leao
- Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, CAHPRI, Maastricht University Medical Center, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands.
| | | | | | - Milena Pavlova
- Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, CAHPRI, Maastricht University Medical Center, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
| | - Wim Groot
- Department of Health Services Research, Faculty of Health, Medicine and Life Sciences, CAHPRI, Maastricht University Medical Center, Maastricht University, P.O. Box 616, 6200 MD, Maastricht, The Netherlands
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Tsai WC, Huang KH, Chen PC, Chang YC, Chen MS, Lee CB. Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single-payer health system. Soc Sci Med 2023; 326:115930. [PMID: 37146356 DOI: 10.1016/j.socscimed.2023.115930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Revised: 02/14/2023] [Accepted: 04/25/2023] [Indexed: 05/07/2023]
Abstract
BACKGROUND Enrollment in and adherence to a diabetes pay-for-performance (P4P) program can lead to desirable processes and outcomes of diabetes care. However, knowledge is limited on the potential exclusion of patients with individual or neighborhood social risks or interruption of services in the disease-specific P4P program without mandatory participation under a single-payer health system. OBJECTIVE To investigate the impact of individual and neighborhood social risks on exclusion from and adherence to the diabetes P4P program of patients with type 2 diabetes (T2D) in Taiwan. METHODS This study used data from Taiwan's 2009-2017 population-based National Health Insurance Research Database, 2010 Population and Housing Census, and 2010 Income Tax Statistics. A retrospective cohort study was conducted, and study populations were identified from 2012 to 2014. The first cohort comprised 183,806 patients with newly diagnosed T2D, who had undergone follow up for 1 year; the second cohort consisted of 78,602 P4P patients who had undergone follow up for 2 years after P4P enrollment. Binary logistic regression models were used to examine the associations of social risks with exclusion from and adherence to the diabetes P4P program. RESULTS T2D patients with higher individual social risks were more likely to be excluded from the P4P program, but those with higher neighborhood-level social risks were slightly less likely to be excluded. T2D patients with the higher individual- or neighborhood-level social risks showed less likelihood of adhering to the program, and the person-level coefficient was stronger in magnitude than the neighborhood-level one. CONCLUSIONS Our results indicate the importance of individual social risk adjustment and special financial incentives in disease-specific P4P programs. Strategies for improving program adherence should consider individual and neighborhood social risks.
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Affiliation(s)
- Wen-Chen Tsai
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Kuang-Hua Huang
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Pei-Chun Chen
- International Master Program for Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan
| | - Yu-Chia Chang
- Department of Long Term Care, National Quemoy University, 1 University Rd., Jinning Township, Kinmen County, 892009, Kinmen, Taiwan; Department of Healthcare Administration, Asia University, 500, Lioufeng Rd., Wufeng, Taichung City, 41354, Taiwan
| | - Michael S Chen
- Department of Social Welfare, National Chung Cheng University, 168 Section 1, University Rd., Minhsiung, Chiayi, 621301, Taiwan
| | - Chiachi Bonnie Lee
- Department of Health Services Administration, College of Public Health, China Medical University, 100 Section 1, Jingmao Road, Beitun District, Taichung City, 406040, Taiwan.
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Krysa JA, Pohar Manhas KJ, Loyola-Sanchez A, Casha S, Kovacs Burns K, Charbonneau R, Ho C, Papathanassoglou E. Mobilizing registry data for quality improvement: A convergent mixed-methods analysis and application to spinal cord injury. FRONTIERS IN REHABILITATION SCIENCES 2023; 4:899630. [PMID: 37077292 PMCID: PMC10109451 DOI: 10.3389/fresc.2023.899630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Accepted: 03/17/2023] [Indexed: 04/05/2023]
Abstract
IntroductionThe rising prevalence of complex chronic conditions and growing intricacies of healthcare systems emphasizes the need for interdisciplinary partnerships to advance coordination and quality of rehabilitation care. Registry databases are increasingly used for clinical monitoring and quality improvement (QI) of health system change. Currently, it is unclear how interdisciplinary partnerships can best mobilize registry data to support QI across care settings for complex chronic conditions.PurposeWe employed spinal cord injury (SCI) as a case study of a highly disruptive and debilitating complex chronic condition, with existing registry data that is underutilized for QI. We aimed to compare and converge evidence from previous reports and multi-disciplinary experts in order to outline the major elements of a strategy to effectively mobilize registry data for QI of care for complex chronic conditions.MethodsThis study used a convergent parallel-database variant mixed design, whereby findings from a systematic review and a qualitative exploration were analyzed independently and then simultaneously. The scoping review used a three-stage process to review 282 records, which resulted in 28 articles reviewed for analysis. Concurrent interviews were conducted with multidisciplinary-stakeholders, including leadership from condition-specific national registries, members of national SCI communities, leadership from SCI community organizations, and a person with lived experience of SCI. Descriptive analysis was used for the scoping review and qualitative description for stakeholder interviews.ResultsThere were 28 articles included in the scoping review and 11 multidisciplinary-stakeholders in the semi-structured interviews. The integration of the results allowed the identification of three key learnings to enhance the successful design and use of registry data to inform the planning and development of a QI initiative: enhance utility and reliability of registry data; form a steering committee lead by clinical champions; and design effective, feasible, and sustainable QI initiatives.ConclusionThis study highlights the importance of interdisciplinary partnerships to support QI of care for persons with complex conditions. It provides practical strategies to determine mutual priorities that promote implementation and sustained use of registry data to inform QI. Learnings from this work could enhance interdisciplinary collaboration to support QI of care for rehabilitation for persons with complex chronic conditions.
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Affiliation(s)
- Jacqueline A. Krysa
- Neurosciences, Rehabilitation and Vision, Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Kiran J. Pohar Manhas
- Neurosciences, Rehabilitation and Vision, Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
- Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Adalberto Loyola-Sanchez
- Neurosciences, Rehabilitation and Vision, Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Steve Casha
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Katharina Kovacs Burns
- School of Public Health, University of Alberta, Edmonton, AB, Canada
- Department of Clinical Quality Metrics, Alberta Health Services, Edmonton, AB, Canada
| | - Rebecca Charbonneau
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Chester Ho
- Neurosciences, Rehabilitation and Vision, Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
- Division of Physical Medicine and Rehabilitation, University of Alberta, Edmonton, AB, Canada
| | - Elizabeth Papathanassoglou
- Neurosciences, Rehabilitation and Vision, Strategic Clinical Network, Alberta Health Services, Edmonton, AB, Canada
- Faculty of Nursing, University of Alberta, Edmonton, AB, Canada
- Correspondence: Elizabeth Papathanassoglou
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Morales DR, Minchin M, Kontopantelis E, Roland M, Sutton M, Guthrie B. Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis. BMJ 2023; 380:e072098. [PMID: 36948515 PMCID: PMC10031759 DOI: 10.1136/bmj-2022-072098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVE To determine whether the withdrawal of the Quality and Outcomes Framework (QOF) scheme in primary care in Scotland in 2016 had an impact on selected recorded quality of care, compared with England where the scheme continued. DESIGN Controlled interrupted time series regression analysis. SETTING General practices in Scotland and England. PARTICIPANTS 979 practices with 5 599 171 registered patients in Scotland, and 7921 practices with 56 270 628 registered patients in England in 2013-14, decreasing to 864 practices in Scotland and 6873 in England in 2018-19, mainly due to practice mergers. MAIN OUTCOME MEASURES Changes in quality of care at one year and three years after withdrawal of QOF financial incentives in Scotland at the end of the 2015-16 financial year for 16 indicators (two complex processes, nine intermediate outcomes, and five treatments) measured annually for financial years from 2013-14 to 2018-19. RESULTS A significant decrease in performance was observed for 12 of the 16 quality of care indicators in Scotland one year after QOF was abolished and for 10 of the 16 indicators three years after QOF was abolished, compared with England. At three years, the absolute percentage point difference between Scotland and England was largest for recording (by tick box) of mental health care planning (-40.2 percentage points, 95% confidence interval -45.5 to -35.0) and diabetic foot screening (-22.8, -33.9 to -11.7). Substantial reductions were, however, also observed for intermediate outcomes, including blood pressure control in patients with peripheral arterial disease (-18.5, -22.1 to -14.9), stroke or transient ischaemic attack (-16.6, -20.6 to -12.7), hypertension (-13.7, -19.4 to -7.9), diabetes (-12.7, -15.0 to -12.4), or coronary heart disease (-12.8, -14.9 to -10.8), and for glycated haemoglobin control in people with HbA1c levels ≤75 mmol/mol (-5.0, -8.4 to -1.5). No significant differences were observed between Scotland and England for influenza immunisation and antiplatelet or anticoagulant treatment for coronary heart disease three years after withdrawal of incentives. CONCLUSION The abolition of financial incentives in Scotland was associated with reductions in recorded quality of care for most performance indicators. Changes to pay for performance should be carefully designed and implemented to monitor and respond to any reductions in care quality.
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Affiliation(s)
- Daniel R Morales
- Division of Population Health and Genomics, University of Dundee, UK
| | - Mark Minchin
- National Institute for Health and Care Excellence, Centre for Guidelines, Manchester, UK
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
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Bae KB. The effect of pay for performance on work attitudes in the private, public, and nonprofit sectors: A panel study from South Korea. INTERNATIONAL REVIEW OF ADMINISTRATIVE SCIENCES 2023; 89:186-201. [DOI: 10.1177/00208523211027329] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
The purpose of this study is to examine the differing effects of pay for performance on organizational commitment and job satisfaction in the public, private, and nonprofit sectors. Using data from the Korean Labor and Income Panel Study, this research found that pay for performance has a positive relationship with job satisfaction and organizational commitment in the private sector, a negative relationship with job satisfaction in the public sector, and a negative relationship with organizational commitment in the nonprofit sector. Points for practitioners When organizations in the public and nonprofit sectors begin adopting policies to increase extrinsic motivation, managers and scholars should carefully consider the negative effects of monetary incentives on job satisfaction and organizational commitment. The public sector emphasizes public values and public interests, which explains the significant effect of pay for performance on job satisfaction; meanwhile, the fact that the nonprofit sector focuses on organizational missions and goals, stakeholders, and employee motivation explains the positive effect of pay for performance on organizational commitment.
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Bour SS, Raaijmakers LHA, Bischoff EWMA, Goossens LMA, Rutten-van Mölken MPMH. How Can a Bundled Payment Model Incentivize the Transition from Single-Disease Management to Person-Centred and Integrated Care for Chronic Diseases in the Netherlands? INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:3857. [PMID: 36900870 PMCID: PMC10001506 DOI: 10.3390/ijerph20053857] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 06/18/2023]
Abstract
To stimulate the integration of chronic care across disciplines, the Netherlands has implemented single-disease management programmes (SDMPs) in primary care since 2010; for example, for COPD, type 2 diabetes mellitus, and cardiovascular diseases. These disease-specific chronic care programmes are funded by bundled payments. For chronically ill patients with multimorbidity or with problems in other domains of health, this approach was shown to be less fit for purpose. As a result, we are currently witnessing several initiatives to broaden the scope of these programmes, aiming to provide truly person-centred integrated care (PC-IC). This raises the question if it is possible to design a payment model that would support this transition. We present an alternative payment model that combines a person-centred bundled payment with a shared savings model and pay-for-performance elements. Based on theoretical reasoning and results of previous evaluation studies, we expect the proposed payment model to stimulate integration of person-centred care between primary healthcare providers, secondary healthcare providers, and the social care domain. We also expect it to incentivise cost-conscious provider-behaviour, while safeguarding the quality of care, provided that adequate risk-mitigating actions, such as case-mix adjustment and cost-capping, are taken.
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Affiliation(s)
- Sterre S. Bour
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
| | - Lena H. A. Raaijmakers
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Erik W. M. A. Bischoff
- Department of Primary and Community Care, Radboud Institute for Health Sciences, Radboud University Medical Center, 6525 GA Nijmegen, The Netherlands
| | - Lucas M. A. Goossens
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
- Erasmus Choice Modelling Centre, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
| | - Maureen P. M. H. Rutten-van Mölken
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
- Erasmus Choice Modelling Centre, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
- Institute for Medical Technology Assessment, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands
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Eriksson T, Levin LÅ, Nedlund AC. The introduction of a value-based reimbursement programme-Alignment and resistance among healthcare providers. Int J Health Plann Manage 2023; 38:129-148. [PMID: 36109866 PMCID: PMC10087818 DOI: 10.1002/hpm.3574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/16/2022] [Accepted: 08/31/2022] [Indexed: 01/05/2023] Open
Abstract
Reimbursement programmes are used to manage care through financial incentives. However, their effects are mixed and the programmes can motivate behaviour that goes against professional values. Value-based reimbursement programmes may better align professional values with financial incentives. The aim of this study is to analyse if and how healthcare providers adapt their practices to a value-based reimbursement programme that combines bundled payment with performance-based payment. Forty-one semi-structured interviews were conducted with representatives from healthcare providers within spine surgery in Sweden. Data were analysed using thematic analysis with an abductive approach and a conceptual framework based on neo-institutional theory. Healthcare providers were positive to the idea of a value-based reimbursement programme. However, during its introduction it became evident that some aspects were easier to adapt to than others. The bundled payment provided a more comprehensive picture of the patients' needs but to an increased administrative burden. Due to the financial impact of the bundled payment, healthcare providers tried to decrease the amount of post-discharge care. The performance-based payment was appreciated. However, the lack of financial impact and transparency in how the payment was calculated caused providers to neglect it. Healthcare providers adapted their practices to, but also resisted aspects of the value-based reimbursement programme. Resistance was mainly caused by lack of understanding of how to interpret and act on new information. Providers had to face unfamiliar situations, which they did not know how to handle. Better IT-facilitation and clearer definition of related care is needed to strengthen the value-based reimbursement programme among healthcare providers. A value-based reimbursement programme seems to better align professional values with financial incentives.
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Affiliation(s)
- Thérèse Eriksson
- Division of Society and Health (SH), Department of Health, Medicine and Caring Sciences (HMV), Linköping University, Linkoping, Sweden
| | - Lars-Åke Levin
- Division of Society and Health (SH), Department of Health, Medicine and Caring Sciences (HMV), Linköping University, Linkoping, Sweden
| | - Ann-Charlotte Nedlund
- Division of Society and Health (SH), Department of Health, Medicine and Caring Sciences (HMV), Linköping University, Linkoping, Sweden
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Bayoumi I, Whitehead M, Li W, Kurdyak P, Glazier RH. Association of physician financial incentives with primary care enrolment of adults with serious mental illnesses in Ontario: a retrospective observational population-based study. CMAJ Open 2023; 11:E1-E12. [PMID: 36627127 PMCID: PMC9842098 DOI: 10.9778/cmajo.20210190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Financial incentives may improve primary care access for adults with schizophrenia or bipolar disorder (serious mental illness [SMI]). We studied the association between receipt of the SMI financial premium paid to primary care physicians and rostering of adults with SMI in different patient enrolment models (PEMs), including enhanced fee-for-service and capitation-based models with and without interdisciplinary team-based care. METHODS We conducted a retrospective cohort study involving Ontario adults (≥18 yr) with SMI in PEM practices, in fiscal years 2016/17 and 2017/18. Using negative binomial models, we examined relations between rostering and the primary care model and the contribution of the incentive. Similar models were developed for adults with type 1 or 2 diabetes mellitus and the general population. RESULTS Among 9730 physicians in PEM practices, 4866 (50.0%) received a premium and 448 319 (88.4%) people with SMI in PEMs were rostered. Compared with enhanced fee for service, the likelihood of rostering people with SMI was 3.0% higher for patients in capitation with team-based care (adjusted relative risk [RR] 1.03, 95% confidence interval [CI] 1.02-1.04), with similar results for capitation without team-based care (adjusted RR 1.00 95% CI 0.99-1.01). Rostering for people with diabetes was similar in team-based care (adjusted RR 1.02, 95% CI 1.02-1.03) but higher in capitation without team-based care (adjusted RR 1.03, 95% CI 1.02-1.03) and slightly higher for the Ontario population (team-based care 1.04, 95% CI 1.04-1.05, capitation without team-based care 1.03, 95% CI 1.03-1.04). INTERPRETATION Rostering of people with SMI was lower than for the general population. Additional policy measures are needed to address persisting inequities and to promote rostering of this underserved population with complex needs.
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Affiliation(s)
- Imaan Bayoumi
- ICES Queen's (Bayoumi, Whitehead, Li), Queen's University, Kingston, Ont.; ICES Central (Kurdyak, Glazier), Toronto, Ont.; Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; Centre for Addiction and Mental Health (Kurdyak), Toronto, Ont.; Department of Psychiatry (Kurdyak), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto and St. Michael's Hospital; MAP Centre for Urban Health Solutions (Glazier), St. Michael's Hospital, Toronto, Ont.
| | - Marlo Whitehead
- ICES Queen's (Bayoumi, Whitehead, Li), Queen's University, Kingston, Ont.; ICES Central (Kurdyak, Glazier), Toronto, Ont.; Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; Centre for Addiction and Mental Health (Kurdyak), Toronto, Ont.; Department of Psychiatry (Kurdyak), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto and St. Michael's Hospital; MAP Centre for Urban Health Solutions (Glazier), St. Michael's Hospital, Toronto, Ont
| | - Wenbin Li
- ICES Queen's (Bayoumi, Whitehead, Li), Queen's University, Kingston, Ont.; ICES Central (Kurdyak, Glazier), Toronto, Ont.; Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; Centre for Addiction and Mental Health (Kurdyak), Toronto, Ont.; Department of Psychiatry (Kurdyak), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto and St. Michael's Hospital; MAP Centre for Urban Health Solutions (Glazier), St. Michael's Hospital, Toronto, Ont
| | - Paul Kurdyak
- ICES Queen's (Bayoumi, Whitehead, Li), Queen's University, Kingston, Ont.; ICES Central (Kurdyak, Glazier), Toronto, Ont.; Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; Centre for Addiction and Mental Health (Kurdyak), Toronto, Ont.; Department of Psychiatry (Kurdyak), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto and St. Michael's Hospital; MAP Centre for Urban Health Solutions (Glazier), St. Michael's Hospital, Toronto, Ont
| | - Richard H Glazier
- ICES Queen's (Bayoumi, Whitehead, Li), Queen's University, Kingston, Ont.; ICES Central (Kurdyak, Glazier), Toronto, Ont.; Department of Family Medicine (Bayoumi), Queen's University, Kingston, Ont.; Centre for Addiction and Mental Health (Kurdyak), Toronto, Ont.; Department of Psychiatry (Kurdyak), University of Toronto; Department of Family and Community Medicine (Glazier), University of Toronto and St. Michael's Hospital; MAP Centre for Urban Health Solutions (Glazier), St. Michael's Hospital, Toronto, Ont
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Bååthe F, von Knorring M, Isaksson-Rø K. How hospital top managers reason about the central leadership task of balancing quality of patient care, economy and professionals' engagement: an interview study. Leadersh Health Serv (Bradf Engl) 2022; ahead-of-print:261-274. [PMID: 36573612 PMCID: PMC10427974 DOI: 10.1108/lhs-02-2022-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/27/2022] [Accepted: 10/04/2022] [Indexed: 12/28/2022]
Abstract
PURPOSE This study aims to deepen the understanding of how top managers reason about handling the relationships between quality of patient care, economy and professionals' engagement. DESIGN/METHODOLOGY/APPROACH Qualitative design. Individual in-depth interviews with all members of the executive management team at an emergency hospital in Norway were analysed using reflexive thematic method. FINDINGS The top managers had the intention to balance between quality of patient care, economy and professionals' engagement. This became increasingly difficult in times of high internal or external pressures. Then top management acted as if economy was the most important focus. PRACTICAL IMPLICATIONS For health-care top managers to lead the pursuit towards increased sustainability in health care, there is a need to balance between quality of patient care, economy and professionals' engagement. This study shows that this balancing act is not an anomaly top-managers can eradicate. Instead, they need to recognize, accept and deliberately act with that in mind, which can create virtuous development spirals where managers and health-professional communicate and collaborate, benefitting quality of patient care, economy and professionals' engagement. However, this study builds on a limited number of participants. More research is needed. ORIGINALITY/VALUE Sustainable health care needs to balance quality of patient care and economy while at the same time ensure professionals' engagement. Even though this is a central leadership task for managers at all levels, there is limited knowledge about how top managers reason about this.
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Affiliation(s)
- Fredrik Bååthe
- Institute for Studies of the Medical Profession, LEFO, Oslo, Norway; Institute of Stress Medicine at Region Västra Götaland, Gothenburg, Sweden and Institute of Health and Care Sciences, Sahlgrenska Academy at Gothenburg University, Gothenburg, Sweden
| | - Mia von Knorring
- Department of Learning, Informatics, Management and Ethics, Medical Management Centre, Karolinska Institutet, Stockholm, Sweden
| | - Karin Isaksson-Rø
- Institute for Studies of the Medical Profession, LEFO, Oslo, Norway and Department of Behavioural Sciences in Medicine, Institute of Basic Medical Sciences, Medical Faculty, University of Oslo, Oslo, Norway
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Wuebker A. Ways to Improve Hospital Quality - A Health System Perspective Comment on "Hospitals Bending the Cost Curve With Increased Quality: A Scoping Review Into Integrated Hospital Strategies". Int J Health Policy Manag 2022; 12:7422. [PMID: 36300254 PMCID: PMC10125075 DOI: 10.34172/ijhpm.2022.7422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Accepted: 09/07/2022] [Indexed: 11/07/2022] Open
Abstract
Wackers and colleagues' scoping review provides an informative and well-structured overview of hospital-based case studies focusing on integrated hospital strategies that seek to improve quality, while reducing or containing costs. Wackers et al take a hospital level perspective and evaluate facilitators and barriers to the successful implementation of those hospital strategies. I complement the hospital level perspective of Wackers et al with an analysis from a health system perspective. Regulations at the superordinate system level might influence decisions at the hospital level that are relevant for costs and quality of care. In this commentary, I discuss how interventions at the system level might affect hospital quality. The results suggest that especially competition between hospitals, pay for performance (PfP) initiatives in combination with publication of quality information, but also greater experience of hospital staff (as proxied by the volume outcome relationship) may provide impulses for improving quality of care.
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Affiliation(s)
- Ansgar Wuebker
- RWI – Leibniz-Institute for Economic Research, Essen, Germany
- Leibniz Science Campus Ruhr, Essen, Germany
- Hochschule Harz, Wernigerode, Germany
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Bramwell D, Hotham S, Peckham S, Checkland K, Forbes LJL. Evaluation of the introduction of QOF quality improvement modules in English general practice: early findings from a rapid, qualitative exploration of implementation. BMJ Open Qual 2022; 11:bmjoq-2022-001960. [PMID: 36162934 PMCID: PMC9516148 DOI: 10.1136/bmjoq-2022-001960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background A 2018 review of the English primary care pay-for-performance scheme, the Quality and Outcomes Framework, suggested that it should evolve to better support holistic, patient-centred care and leadership for quality improvement (QI). From 2019, as part of the vision of change, financially incentivised QI cycles (initially in prescribing safety and end-of-life care), were introduced into the scheme. Objectives To conduct a rapid evaluation of general practice staff attitudes, experiences and plans in relation to the implementation of the first two QI modules. This study was commissioned by NHS England and will inform development of the QI programme. Methods Semistructured telephone interviews were conducted with 25 practice managers from a range of practices across England. Interviews were audio recorded with consent and transcribed verbatim. Anonymised data were reflexively thematically analysed using the framework method of analysis to identify common themes across the interviews. Results Participants reported broadly favourable views of incentivised QI, suggesting the prescribing safety module was easier to implement than the end-of-life module. Additional staff time needed and challenges of reviewing activities with other practices were reported as concerns. Some highlighted that local flexibility and influence on subject matter may improve the effectiveness of QI. Several questioned the choices of topic, recognising greater need and potential for improving quality of care in other clinical areas. Conclusion Practices supported the idea of financial incentivisation of QI, however, it will be important to ensure that focus on QI cycles in specific clinical areas does not have unintended effects. A key issue will be keeping up momentum with the introduction of new modules each year which are time consuming to carry out for time poor General Practitioners (GPs)/practices.
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Affiliation(s)
- Donna Bramwell
- Centre for Primary Care and Health Services Research, Health Organisation, Policy and Economics (HOPE) Group, University of Manchester, Manchester, UK
| | - Sarah Hotham
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Stephen Peckham
- Centre for Health Services Studies, University of Kent, Canterbury, UK
- Department of Health Services and Policy Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, Health Organisation, Policy and Economics (HOPE) Group, University of Manchester, Manchester, UK
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Jackson J, Ruffini O, Livet M, Urick B. Funding community pharmacy dispensing: A qualitative exploration of current and alternate models leading to the development of quality focused funding principles. Health Policy 2022; 126:1263-1268. [DOI: 10.1016/j.healthpol.2022.09.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Revised: 09/06/2022] [Accepted: 09/26/2022] [Indexed: 11/26/2022]
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Wilding A, Munford L, Guthrie B, Kontopantelis E, Sutton M. Family doctor responses to changes in target stringency under financial incentives. JOURNAL OF HEALTH ECONOMICS 2022; 85:102651. [PMID: 35858512 DOI: 10.1016/j.jhealeco.2022.102651] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 06/29/2022] [Accepted: 06/30/2022] [Indexed: 06/15/2023]
Abstract
Healthcare providers may game when faced with targets. We examine how family doctors responded to a temporary but substantial increase in the stringency of targets determining payments for controlling blood pressure amongst younger hypertensive patients. We apply difference-in-differences and bunching techniques to data from electronic health records of 107,148 individuals. Doctors did not alter the volume or composition of lists of their hypertension patients. They did increase treatment intensity, including a 1.2 percentage point increase in prescribing antihypertensive medicines. They also undertook more blood pressure measurements. Multiple testing increased by 1.9 percentage points overall and by 8.8 percentage points when first readings failed more stringent target. Exemption of patients from reported performance increased by 0.8 percentage points. Moreover, the proportion of patients recorded as exactly achieving the more stringent target increased by 3.1 percentage points to 16.6%. Family doctors responded as intended and gamed when set more stringent pay-for-performance targets.
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Affiliation(s)
- Anna Wilding
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K..
| | - Luke Munford
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K
| | - Bruce Guthrie
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, U.K
| | - Evangelos Kontopantelis
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K
| | - Matt Sutton
- Health Organisation, Policy and Economics, School of Health Sciences, University of Manchester, Suite 12, 7th Floor, Williamson Building, Oxford Road, Manchester M13 9PL, U.K.; Melbourne Institute: Applied Economic and Social Research, University of Melbourne, Australia
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Mather M, Pettigrew LM, Navaratnam S. Barriers and facilitators to clinical behaviour change by primary care practitioners: a theory-informed systematic review of reviews using the Theoretical Domains Framework and Behaviour Change Wheel. Syst Rev 2022; 11:180. [PMID: 36042457 PMCID: PMC9429279 DOI: 10.1186/s13643-022-02030-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 07/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Understanding the barriers and facilitators to behaviour change by primary care practitioners (PCPs) is vital to inform the design and implementation of successful Behaviour Change Interventions (BCIs), embed evidence-based medicine into routine clinical practice, and improve quality of care and population health outcomes. METHODS A theory-led systematic review of reviews examining barriers and facilitators to clinical behaviour change by PCPs in high-income primary care contexts using PRISMA. Embase, MEDLINE, PsychInfo, HMIC and Cochrane Library were searched. Content and framework analysis was used to map reported barriers and facilitators to the Theoretical Domains Framework (TDF) and describe emergent themes. Intervention functions and policy categories to change behaviour associated with these domains were identified using the COM-B Model and Behaviour Change Wheel (BCW). RESULTS Four thousand three hundred eighty-eight reviews were identified. Nineteen were included. The average quality score was 7.5/11. Reviews infrequently used theory to structure their methods or interpret their findings. Barriers and facilitators most frequently identified as important were principally related to 'Knowledge', 'Environmental context and resources' and 'Social influences' TDF domains. These fall under the 'Capability' and 'Opportunity' domains of COM-B, and are linked with interventions related to education, training, restriction, environmental restructuring and enablement. From this, three key areas for policy change include guidelines, regulation and legislation. Factors least frequently identified as important were related to 'Motivation' and other psychological aspects of 'Capability' of COM-B. Based on this, BCW intervention functions of persuasion, incentivisation, coercion and modelling may be perceived as less relevant by PCPs to change behaviour. CONCLUSIONS PCPs commonly perceive barriers and facilitators to behaviour change related to the 'Capability' and 'Opportunity' domains of COM-B. PCPs may lack insight into the role that 'Motivation' and aspects of psychological 'Capability' have in behaviour change and/or that research methods have been inadequate to capture their function. Future research should apply theory-based frameworks and appropriate design methods to explore these factors. With no 'one size fits all' intervention, these findings provide general, transferable insights into how to approach changing clinical behaviour by PCPs, based on their own views on the barriers and facilitators to behaviour change. SYSTEMATIC REVIEW REGISTRATION A protocol was submitted to the London School of Hygiene and Tropical Medicine via the Ethics and CARE form submission on 16.4.2020, ref number 21478 (available on request). The project was not registered on PROSPERO.
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Affiliation(s)
- Melissa Mather
- Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells Hospital, Tonbridge Road, Pembury, Tunbridge Wells, Kent, TN2 4QJ, UK.
| | - Luisa M Pettigrew
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Pl, London, WC1H 9SH, UK.,UCL Department of Primary Care and Population Health, UCL Medical School, Upper Third Floor, Rowland Hill Street, London, NW3 2PF, UK
| | - Stefan Navaratnam
- Northern Devon Healthcare NHS Trust, North Devon District Hospital, Raleigh Heights, Barnstaple, EX31 4JB, UK
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Park Y, Kim JH, Lee KS. Changes in cesarean section rate before and after the end of the Korean Value Incentive Program. Medicine (Baltimore) 2022; 101:e29952. [PMID: 35984147 PMCID: PMC9388010 DOI: 10.1097/md.0000000000029952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The Korean government implemented a value incentive program providing incentives to providers based on C-section rates, with the rates being publicized. The program ended in 2014 after the administration decided that the effects of the incentive program were limited. In this report, we analyzed changes in C-section rates with the value incentive program. METHODS The analysis used claim data from Korea's National Health Insurance. The study period (2011-2016) was divided into two phases: before and after the program. This study included 95 providers that were tertiary or general hospitals having more than 200 deliveries per year during the study period. The dependent variable was the risk-adjusted C-section rate. Independent variables included time and hospital characteristics such as hospital type, district, and ownership. Interrupted time series analysis was performed to analyze the data. RESULTS Our results showed that risk-adjusted C-section rates increased immediately after the end of the incentive program for C-sections. The immediate effect of intervention, a change of 1.73% (P < .05), was statistically significant, as was the trend after intervention, at 0.21% (P < .0001). The slope showed an increase after the intervention to 0.25% per medical institution, which was contrary to the trend of the preintervention decline (negative slope). CONCLUSION Risk-adjusted C-section rates increased immediately after the discontinuation of a value incentive program. Tertiary hospitals showed greater increases in C-section rates than general hospitals after the intervention.
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Affiliation(s)
- YouHyun Park
- Department of Health Administration, Yonsei University Graduate School, Wonju, Republic of Korea
| | - Jae-hyun Kim
- Department of Healthcare Administration, Dankook University, Cheonan, Republic of Korea
| | - Kwang-soo Lee
- Department of Health Administration, Yonsei University Graduate School, Wonju, Republic of Korea
- *Correspondence: Kwang-soo Lee, Department of Health Administration, Yonsei University, 1, Yeonsedae-gil, Heungeop-myeon, Wonju-si 26493, Gangwon-do, Republic of Korea (e-mail: )
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Brouwers J, Claessens F, Castro EM, Van Wilder A, Eeckloo K, Bruyneel L, De Ridder D, Vanhaecht K. Cornerstones of a sustainable national quality policy: A qualitative study based on international expert opinions. Int J Health Plann Manage 2022; 37:3312-3328. [PMID: 35983647 DOI: 10.1002/hpm.3559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 07/06/2022] [Accepted: 07/23/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND National initiatives launched to improve the quality of care have grown exponentially over the last decade. Public reporting, accreditation and governmental inspection form the basis for quality in Flemish (Belgian) hospitals. Due to the lack of evidence for these national initiatives and the questions concerning their sustainability, our research aims to identify cornerstones of a sustainable national quality policy for acute-care hospitals based on international expert opinion. METHODS A qualitative study was conducted using in-depth semi-structured interviews with 12 renowned international quality and patient safety experts selected by purposive sampling. Interviews focussed on participants' perspectives and their recommendations for a future, sustainable quality policy. Inductive analysis was carried out with themes being generated from the data using the constant comparison method. RESULTS Three major and five minor themes were identified and integrated into a framework as a basis for national quality policies. Quality culture, minimum requirements for quality education and quality control as well as continuous learning and improvement act as cornerstones of this framework. CONCLUSIONS Complementary to the current national policy, this study demonstrated the need for profound attention to quality cultures in acute-care hospitals. Policymakers need to provide a control system and minimum requirements for quality education for all healthcare workers. A model for continuous learning and improvement with data feedback loops has to be installed in each hospital to obtain a sustainable quality system. This framework can inspire policymakers to further develop bottom-up initiatives in co-governance with all relevant stakeholders adapted to individual hospitals' context.
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Affiliation(s)
- Jonas Brouwers
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Orthopaedics, University Hospitals Leuven, Leuven, Belgium
| | - Fien Claessens
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Eva Marie Castro
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Quality Management, Regional Hospital Heilig Hart Tienen, Tienen, Belgium
| | - Astrid Van Wilder
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Kristof Eeckloo
- Strategic Policy Unit, Ghent University Hospital, Ghent, Belgium.,Department of Primary Care and Public Health, Ghent University, Ghent, Belgium
| | - Luk Bruyneel
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium
| | - Dirk De Ridder
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
| | - Kris Vanhaecht
- Leuven Institute for Healthcare Policy, KU Leuven - University of Leuven, Leuven, Belgium.,Department of Quality Management, University Hospitals Leuven, Leuven, Belgium
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Jin Y, Tian W, Yu Y, Pan W, Yuan B. Incentives Promoting Contracted Family Doctor Service Policy to Improve Continuity and Coordination in Diabetes Patient Management Care in China. Front Public Health 2022; 10:843217. [PMID: 35910878 PMCID: PMC9334846 DOI: 10.3389/fpubh.2022.843217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Accepted: 05/17/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundAs the first step toward building a gatekeeping system in China, the governments have introduced a contracted family doctor service (CFDS) policy in primary healthcare (PHC) facilities. This study was to examine the association between apply of incentive to improve the implementation of CFDS and the performance on diabetes management care.MethodsWe conducted a cross-sectional study in 72 PHC facilities in 6 cities that piloted the CFDS. Multivariate regression models were applied, based on a sample of 827 PHC providers and 420 diabetic patients.ResultsPHC providers who reported the performance being linked with increased income were 168.1 and 78.0% more likely to have good continuity and coordination of diabetes patient management care, respectively. Additional one-point percentage of PHC providers whose performance on CFDS was assessed was associated with 7.192 times higher probability of patients with control of blood glucose.DiscussionInclusion of incentives rewarding better performance on CFDS were associated with better delivery process and outcome performance on diabetes management care.ConclusionDesign and implementation of the incentive should be accompanied with the policy of CFDS, in order to increase the proportion of performance-related income of PHC providers, thereby improving the quality of diabetes management care.
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Affiliation(s)
- Yinzi Jin
- Department of Global Health, School of Public Health, Peking University, Beijing, China
| | - Wenya Tian
- Institute for Global Health and Development, Peking University, Beijing, China
| | - Yahang Yu
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, United States
| | - Wen Pan
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, United States
| | - Beibei Yuan
- Department of Chronic Disease Epidemiology, School of Public Health, Yale University, New Haven, CT, United States
- *Correspondence: Beibei Yuan
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