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Kingsada A. Can financial incentives improve access to care? Evidence from a French experiment on specialist physicians. Soc Sci Med 2024; 352:117018. [PMID: 38901210 DOI: 10.1016/j.socscimed.2024.117018] [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: 02/01/2024] [Revised: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 06/22/2024]
Abstract
In France, addressing balance billing is essential for equitable healthcare access and reducing physician income disparities. The National Health Insurance (NHI) introduced financial incentive programs, namely the "Contract for Access to Care" (CAS) in 2014 and the "Option for Controlled Pricing" (OPTAM) in 2017, to encourage physicians to reduce extra fees and adhere to regulated prices. This study analyzed the impact of these programs on self-employed physicians using a comprehensive administrative dataset covering specialist physicians from 2005 to 2017. The dataset comprised 9891 surgical specialists (30,972 observations) and 6926 medical specialists (21,650 observations) between 2005 and 2017. Applying a difference-in-differences design with a two-way fixed effect model and matching through the "Coarsened Exact Matching" method, the study examined CAS and/or OPTAM membership effects on physicians' activity and fees. The results indicate that both the CAS and OPTAM successfully enhance access to care. Physicians treat more patients, particularly those with lower incomes who might have previously avoided care because of the extra fees. However, an increased patient load translates to a higher workload for physicians. Despite a fee increase, it was observed to be smaller than the surge in activity. Furthermore, if all physicians are appropriately rewarded for their efforts, this improvement in access comes at a cost to NHI. This study's findings provide crucial insights into the nuanced effects of these financial incentive programs on physicians' behavior, highlighting the tradeoff between improved access and increased NHI costs. Ultimately, these findings underscore the complexity of balancing financial incentives, physician workload, and healthcare accessibility in pursuit of a more equitable healthcare system.
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Affiliation(s)
- Aimée Kingsada
- LIRAES and Chaire AgingUP!, Université Paris Cité, 45 rue des Saints-Pères, F-75006 Paris, France.
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Abidova A, Alcântara da Silva P, Moreira S. Payment perception in the emergency department: The mediating role of perceived quality of healthcare and patient satisfaction. Medicine (Baltimore) 2024; 103:e38527. [PMID: 38847693 PMCID: PMC11155609 DOI: 10.1097/md.0000000000038527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/17/2024] [Indexed: 06/10/2024] Open
Abstract
The aim of this research is to identify the main factors associated with patients' payment perception and the effects of these factors on payment perception. Patients admitted between January and December 2016 at an emergency department of a public hospital in Lisbon, Portugal, were included in this study, with a representative sample size of 382 patients. A 5% margin of error and a 95% confidence interval were used, and all the data were collected between May and November 2017. To test the mediation models, stepwise multiple linear regression analysis was used. The effect of doctors on payment perception through satisfaction and through perceived quality of healthcare (PQHC) is explained by 3% and 4% of the variation, respectively, with statistically significant results (P < .01). Moreover, the effect of privacy and meeting expectations on payment perception through PQHC is explained by 4% and 4% of the variation, with statistically significant results (P < .01). Doctors play a crucial role in understanding the patients' payment perception (with direct and indirect effects). Mediators, in turn, strengthen this effect, in which the contribution of PQHC is more significant than that of satisfaction.
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Affiliation(s)
- Alina Abidova
- NOVA University of Lisbon, National School of Public Health, Lisbon, Portugal
| | | | - Sérgio Moreira
- University of Lisbon, Faculty of Psychology, Lisbon, Portugal
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Gifford R, Molleman E, van der Vaart T. It's a jungle out there: Understanding physician payment and its role in group dynamics. Soc Sci Med 2024; 350:116945. [PMID: 38733732 DOI: 10.1016/j.socscimed.2024.116945] [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: 10/16/2023] [Revised: 04/02/2024] [Accepted: 05/03/2024] [Indexed: 05/13/2024]
Abstract
Although collaboration between healthcare professionals is essential for the delivery of effective, efficient, and high-quality care, it remains an ongoing and critical challenge across health systems. As a result, many countries are experimenting with innovative payment and employment models. The literature tends to focus on improving collaboration across organizational and sectoral boundaries, and largely ignores potential barriers to collaborative work between members of the same profession within a single organization. Despite intergroup dynamics and professional boundaries having been shown to restrict patient flow and collaboration between specialties, studies have so far tended to overlook the potential effects of differentiated organizational and payment models on physicians' behaviors and intergroup dynamics. In the present study, we seek to unpack the influence of physicians' payment and employment models on their collaborative behaviors and on intergroup dynamics between specialties, adding to the current scholarship on physician payment and employment by considering how physicians' view and act in response to different structural arrangements. The findings suggest that adopting hybrid models, in which physicians are employed or paid differently within the same organization or practice, creates a bifurcation of the profession whereby physicians across different models are perceived to behave differently and have conflicting professional values. These models are perceived to inhibit collaboration between physicians and complicate hospital governance, restricting the ability to move towards new models of care delivery. These findings can be used as a basis for future work that aims to unpack the reality of physician payment and offer important insights for policies surrounding physician employment.
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Affiliation(s)
- Rachel Gifford
- Department of Health Services Research, Faculty of Health Medicine and Life Sciences, Maastricht University, Maastricht, Netherlands.
| | - Eric Molleman
- Department of Organizational Behavior, Faculty of Economics and Business, University of Groningen, Groningen, Netherlands
| | - Taco van der Vaart
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, Netherlands
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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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Wiler JL, Kosinski LR, Mills TL, Walton J. Where Are All the Specialists? Current Challenges of Integrating Specialty Care Into Population-Based Total Cost of Care Payment Models. Ann Intern Med 2024; 177:375-382. [PMID: 38466999 DOI: 10.7326/m23-2991] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Abstract
The Centers for Medicare & Medicaid Services Innovation Center (CMMI) has set the goal for 100% of traditional Medicare beneficiaries to be part of an accountable care relationship by 2030. Lack of meaningful financial incentives, intolerable or unpredictable risk, infrastructure costs, patient engagement, voluntary participation, and operational complexity have been noted by the provider and health care delivery community as barriers to participation or reasons for exiting programs. In addition, most piloted and implemented population-based total cost of care (PB-TCOC) payment models have focused on the role of the primary care physician being the accountability (that is, attributable) leader of a patient's multifaceted care team as well as acting as the mayor of the "medical neighborhood," leaving the role of specialty care physicians undefined. Successful provider specialist integration into PB-TCOC models includes meaningful participation of specialists in achieving whole-person, high-value care where all providers are financially motivated to participate; there is unambiguous prospective attribution and clearly defined accountability for each participating party throughout the care journey or episode; there is a known care attribution transition accountability plan; there is actionable, transparent, and timely data available with appropriate data development and basic analytic costs covered; and there is advanced payment to the accountable person or entity for management of the care episode that is part of a longitudinal care plan. Payment models should be created to address the 7 challenges raised here if specialists are to be incented to join TCOC models that achieve CMMI's goal.
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Affiliation(s)
- Jennifer L Wiler
- University of Colorado School of Medicine, Aurora, Colorado (J.L.W.)
| | | | | | - James Walton
- JWalton, LLC Healthcare Advisory Services, Dallas, Texas (J.W.)
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Quinn AE, Manns BJ. Creating Incentives to Move Specialists Into the Medical Neighborhood. Ann Intern Med 2024; 177:399-400. [PMID: 38466997 DOI: 10.7326/m24-0198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/13/2024] Open
Affiliation(s)
- Amity E Quinn
- Department of Community Health Sciences and O'Brien Institute for Public Health, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Braden J Manns
- Department of Community Health Sciences, O'Brien Institute for Public Health, Libin Cardiovascular Institute, and Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Hoff EH, Kraft KB, Moe CF, Nylenna M, Østby KA, Mykletun A. The cost of saying no: general practitioners' gatekeeping role in sickness absence certification. BMC Public Health 2024; 24:439. [PMID: 38347474 PMCID: PMC10860288 DOI: 10.1186/s12889-024-17993-1] [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: 12/20/2023] [Accepted: 02/05/2024] [Indexed: 02/15/2024] Open
Abstract
BACKGROUND General practitioners (GPs) have an important gatekeeping role in the Norwegian sickness insurance system. This role includes limiting access to paid sick leave when this is not justified according to sick leave criteria. 85% of GPs in Norway operate within a fee-for-service system that incentivises short consultations and high service provision. In this qualitative study, we explore how GPs practise the gatekeeping role in sickness absence certification. METHODS Qualitative data was collected through six focus group interviews with 33 GPs, working in practices with a minimum of four practising GPs, in different geographical regions across Norway, including both urban and rural areas. Data was analysed using Braune and Clarke's thematic analysis approach. RESULTS Our results indicate that GPs' sick-listing decisions are largely driven by patient demand and preferences for sick leave. GPs reported that they rarely overrule patient requests for sickness absence, including in cases where such requests conflict with the GPs' opinion of whether sick leave is justified or benefits the patient. The degree of effort made to limit unjustified or non-beneficial sick leave seems to depend on the GPs' available time and perceived risk of conflict with the patient. GPs generally expressed dissatisfaction with their role as certifiers of sickness absence. CONCLUSION Our study suggests that GPs' decisions about sickness certification is largely driven by patient preferences. The GPs' gatekeeping function is limited to negotiations about grade and duration of absence spells.
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Affiliation(s)
- Eivor Hovde Hoff
- Norwegian Institute of Public Health (NIPH), Cluster for Health Services Research, Postboks 222, Skøyen, Oslo, N-0213, Norway.
- Office of the Auditor General of Norway, Oslo, Norway.
- Department of Community Medicine, UiT - The Arctic University of Norway, Tromsø, Norway.
- , Myrens verksted 3L, Oslo, 0476, Norway.
| | - Kristian B Kraft
- Norwegian Institute of Public Health (NIPH), Cluster for Health Services Research, Postboks 222, Skøyen, Oslo, N-0213, Norway
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Cathrine F Moe
- Centre for Work and Mental Health, Nordland Hospital Trust, Bodø, Norway
- Faculty of Nursing and Health Sciences, Nord University, Bodø, Norway
| | - Magne Nylenna
- Institute of Health and Society, University of Oslo, Oslo, Norway
| | - Kristian A Østby
- Norwegian Institute of Public Health (NIPH), Cluster for Health Services Research, Postboks 222, Skøyen, Oslo, N-0213, Norway
| | - Arnstein Mykletun
- Norwegian Institute of Public Health (NIPH), Cluster for Health Services Research, Postboks 222, Skøyen, Oslo, N-0213, Norway
- Department of Community Medicine, UiT - The Arctic University of Norway, Tromsø, Norway
- Centre for Work and Mental Health, Nordland Hospital Trust, Bodø, Norway
- Centre for Research and Education in Forensic Psychiatry and Psychology, Haukeland University Hospital, Bergen, Norway
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Quinn AE, Chew DS, Faris P, Au F, James MT, Tonelli M, Manns BJ. Physician Variation and the Impact of Payment Model in Cardiac Imaging. J Am Heart Assoc 2023; 12:e029149. [PMID: 38084753 PMCID: PMC10863764 DOI: 10.1161/jaha.122.029149] [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: 01/09/2023] [Accepted: 10/30/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND The influence of fee-for-service reimbursement on cardiac imaging has not been compared with other payment models. Furthermore, variation in ordering practices is not well understood. METHODS AND RESULTS This retrospective, population-based cohort study using linked administrative data from Alberta, Canada included adults with chronic heart disease (atrial fibrillation, coronary artery disease, and heart failure) seen by cardiac specialists for a new outpatient consultation April 2012 to December 2018. Generalized linear mixed-effects models estimated the association of payment model (including the ability to bill to interpret imaging tests) and the use of cardiac imaging and quantified variation in cardiac imaging. Among 31 685 adults seen by 308 physicians at 136 sites, patients received an observed mean of 0.67 (95% CI, 0.67-0.68) imaging tests per consultation. After adjustment, patients seeing fee-for-service physicians had 2.07 (95% CI, 1.68-2.54) and fee-for-service physicians with ability to interpret had 2.87 (95% CI, 2.16-3.81) times the rate of receiving a test than those seeing salaried physicians. Measured patient, physician, and site effects accounted for 31% of imaging variation and, following adjustment, reduced unexplained site-level variation 40% and physician-level variation 29%. CONCLUSIONS We identified substantial variation in the use of outpatient cardiac imaging related to physician and site factors. Physician payment models have a significant association with imaging use. Our results raise concern that payment models may influence cardiac imaging practice. Similar methods could be applied to identify the source and magnitude of variation in other health care processes and outcomes.
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Affiliation(s)
- Amity E. Quinn
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
| | - Derek S. Chew
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Libin Cardiovascular Institute, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
| | - Peter Faris
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Data and Analytics, Alberta Health ServicesAlbertaCanada
| | - Flora Au
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
| | - Matthew T. James
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
| | - Marcello Tonelli
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
| | - Braden J. Manns
- Department of Medicine, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Libin Cardiovascular Institute, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
- Department of Community Health Sciences, Cumming School of MedicineUniversity of CalgaryAlbertaCanada
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Wackers E, van Dulmen S, Berden B, Kremer J, Stadhouders N, Jeurissen P. Improving Performance in Complex Surroundings: A Mixed Methods Evaluation of Two Hospital Strategies in the Netherlands. Int J Health Policy Manag 2023; 12:7243. [PMID: 37579390 PMCID: PMC10425645 DOI: 10.34172/ijhpm.2023.7243] [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: 03/14/2022] [Accepted: 03/26/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Hospital strategies aimed at increasing quality of care and simultaneously reducing costs show potential to improve healthcare, but knowledge on real-world effectiveness is limited. In 2014, two Dutch hospitals introduced such quality-driven strategies. Our aim was to evaluate contexts, mechanisms, and outcomes of both strategies using multiple perspectives. METHODS We conducted a mixed methods evaluation. Four streams of data were collected and analysed: (1) semi-structured interviewing of 62 stakeholders, such as medical doctors, nurses, managers, general practitioners (GPs), and consultants; (2) financial statements of both organisations and other hospitals in the Netherlands (counterfactual); (3) national database of quality indicators, and patient-reported experiences; and (4) existing material on strategy development and effects. RESULTS Both strategies resulted in a relative decrease in volume of care within the hospital, while quality of care has not been affected negatively. One hospital failed to cut operating costs sufficiently, resulting in declining profit margins. We identified six main mechanisms that impacted these outcomes: (1) Quality-improvement projects spur change and commitment; (2) increased coordination between hospital and primary care leads to substitution of care; (3) insufficient use of data and support hinder quality improvement; (4) scaling down hospital facilities is required to convert volume reductions to cost savings; (5) shared savings through global budgets lead to shared efforts between payer and hospital; and (6) financial security for physicians facilitates shift towards quality-driven care. CONCLUSION This integrated analysis of mixed data sources demonstrated that the institution-wide nature of the strategies has induced a shift from a focus on production towards quality of care. Longer-term (financial) sustainability of hospital strategies aimed at decelerating production growth requires significant efforts in reducing fixed costs. This strategy poses financial risks for the hospital if operating costs are insufficiently reduced or if payer alignment is compromised.
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Affiliation(s)
- Erik Wackers
- Radboud University Medical Center, Radboud Institute for Health Sciences, IQ healthcare, Nijmegen, The Netherlands
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10
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Zare-Zadeh S, Manns BJ, Chew DS, Harrison TG, Au F, Quinn AE. Low-value preoperative cardiac testing before low-risk surgical procedures: a population-based cohort study. CMAJ Open 2023; 11:E451-E458. [PMID: 37220955 PMCID: PMC10212574 DOI: 10.9778/cmajo.20220049] [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: 05/25/2023] Open
Abstract
BACKGROUND Choosing Wisely Canada (CWC) recommends avoiding noninvasive advanced cardiac testing (e.g., exercise stress testing [EST], echocardiography and myocardial perfusion imaging [MPI]) for preoperative assessment in patients scheduled to undergo low-risk noncardiac surgery. In this study, we assessed the temporal trends in testing, overlapping with the introduction of the CWC recommendations in 2014, and patient and provider factors associated with low-value testing. METHODS In this population-based retrospective cohort study, we used linked health administrative data in Alberta, Canada, to identify adult patients who underwent elective noncardiac surgery between Apr. 1, 2011, and Mar. 31, 2019, who had preoperative noninvasive advanced cardiac tests (EST, echocardiography or MPI) within 6 months before surgery. We included electrocardiography as an exploratory outcome. We excluded patients at high risk using the Revised Cardiac Risk Index (score ≥ 1 considered to indicate high risk), and modelled patient and temporal factors associated with the number of tests. RESULTS We identified 1 045 896 elective noncardiac operations performed in 798 599 patients and 25 599 advanced preoperative cardiac tests; 2.1% of operations were preceded by advanced cardiac testing. The incidence of testing increased over the study period, and, by 2018/19, patients were 1.3 times (95% confidence interval 1.2-1.4) more likely to receive a preoperative advanced test compared to 2011/12. Urban patients were more likely to receive a preoperative advanced cardiac test than their rural counterparts. Electrocardiography was the most common preoperative cardiac test, preceding 182 128 procedures (17.4%). INTERPRETATION Preoperative advanced cardiac testing was infrequent in adult Albertans who underwent low-risk elective noncardiac operations. Despite CWC recommendations, the use of some tests appears to be increasing, and there was substantial variation across geographic areas.
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Affiliation(s)
- Siavash Zare-Zadeh
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta
| | - Braden J Manns
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta.
| | - Derek S Chew
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta
| | - Tyrone G Harrison
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta
| | - Flora Au
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta
| | - Amity E Quinn
- Cumming School of Medicine (Zare-Zadeh, Manns, Chew, Harrison, Au), Department of Community Health Sciences (Manns, Harrison, Quinn), Libin Cardiovascular Institute (Manns, Chew) and O'Brien Institute for Public Health (Manns), University of Calgary, Calgary, Alta
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Fan W, Jiang Y, Pei J, Yan P, Qiu L. The impact of medical insurance payment systems on patient choice, provider behavior, and out‐of‐pocket rate: Fee‐for‐service versus diagnosis‐related groups. DECISION SCIENCES 2023. [DOI: 10.1111/deci.12593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023]
Affiliation(s)
- Wenjuan Fan
- School of Management Hefei University of Technology Hefei China
- Key Laboratory of Process Optimization and Intelligent Decision‐making of Ministry of Education Hefei China
| | - Yuanyuan Jiang
- School of Management Hefei University of Technology Hefei China
- Key Laboratory of Process Optimization and Intelligent Decision‐making of Ministry of Education Hefei China
| | - Jun Pei
- School of Management Hefei University of Technology Hefei China
- Key Laboratory of Process Optimization and Intelligent Decision‐making of Ministry of Education Hefei China
| | - Ping Yan
- School of Management Hefei University of Technology Hefei China
- Key Laboratory of Process Optimization and Intelligent Decision‐making of Ministry of Education Hefei China
| | - Liangfei Qiu
- Department of Information Systems and Operations Management, Warrington College of Business University of Florida Gainesville FloridaUnited States
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Boulet E, Barbet I, Hartmann L, Narcy M. L’intégration de médecins prescripteurs en Ehpad : une amélioration de la qualité des soins perçue. SANTE PUBLIQUE (VANDOEUVRE-LES-NANCY, FRANCE) 2023; 34:803-812. [PMID: 37019793 DOI: 10.3917/spub.226.0803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/07/2023]
Abstract
INTRODUCTION Since 2017, the Regional Health Agency of ’Île-de-France’ has implemented an experiment to subsidize the recruitment of part-time doctors in nursing homes, so that residents without a primary care physician can benefit from regular medical follow-up. PURPOSE OF RESEARCH The purpose of the study is to estimate the effects of this experiment: how is it implemented? What are its effects on the perceived quality of care? METHOD The method used was based on a qualitative survey involving semi-structured individual or group interviews. On the whole, 20 professionals, one resident, and two daughters of residents were interviewed in four different nursing homes. RESULTS The investigation shows that this experiment addresses an unmet medical need. However, the recruiting of doctors appears to be difficult and significant delays have been noted. The experimentation is considered to be beneficial by professionals and recipients: It provides an opportunity to re-evaluate prescriptions in time, to prevent the deterioration of the residents’ health and to reduce the need for emergency services. These physicians are involved in the care for cognitive disorders and play an important role in the support of the end-of-life. CONCLUSIONS The experimentation has a positive effect on the perceived quality of care, according to professionals as well as residents or their relatives, which could provide a rationale for its sustainability or even its extension.
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Affiliation(s)
- Elsa Boulet
- Laboratoire interdisciplinaire de recherche en sciences de l’action (Lirsa) – Conservatoire national des arts et métiers (Cnam) – Paris – France. Centre d’études de l’emploi et du travail (CEET) – Cnam – Paris – France
| | - Isabelle Barbet
- Centre d’études et de recherche en informatique et communication (Cédric) – Cnam – Paris – France
| | - Laurence Hartmann
- Laboratoire interdisciplinaire de recherche en sciences de l’action (Lirsa) – Conservatoire national des arts et métiers (Cnam) – Paris – France
| | - Mathieu Narcy
- Laboratoire interdisciplinaire de recherche en sciences de l’action (Lirsa) – Conservatoire national des arts et métiers (Cnam) – Paris – France. Centre d’études de l’emploi et du travail (CEET) – Cnam – Paris – France
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Waitzberg R, Gottlieb N, Quentin W, Busse R, Greenberg D. Dual Agency in Hospitals: What Strategies Do Managers and Physicians Apply to Reconcile Dilemmas Between Clinical and Economic Considerations? Int J Health Policy Manag 2022; 11:1823-1834. [PMID: 34634873 PMCID: PMC9808238 DOI: 10.34172/ijhpm.2021.87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 07/17/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Hospital professionals are "dual agents" who may face dilemmas between their commitment to patients' clinical needs and hospitals' financial sustainability. This study examines whether and how hospital professionals balance or reconcile clinical and economic considerations in their decision-making in two countries with activity-based payment systems. METHODS We conducted 46 semi-structured interviews with hospital managers, chief physicians and practicing physicians in five German and five Israeli hospitals in 2018/2019. We used thematic analysis to identify common topics and patterns of meaning. RESULTS Hospital professionals report many situations in which activity-based payment incentivizes proper treatment, and clinical and economic considerations are aligned. This is the case when efficiency can be improved, eg, by curbing unnecessary expenditures or specializing in certain procedures. When considerations are misaligned, hospital professionals have developed a range of strategies that may contribute to balancing competing considerations. These include 'reshaping management,' such as better planning of the entire course of treatment and improvement of the coding; and 'reframing decision-making,' which involves working with averages and developing tool-kits for decision-making. CONCLUSION Misalignment of economic and clinical considerations does not necessarily have negative implications, if professionals manage to balance and reconcile them. Context is important in determining if considerations can be reconciled or not. Reconciling strategies are fragile and can be easily disrupted depending on context. Creating tool-kits for better decision-making, planning the treatment course in advance, working with averages, and having interdisciplinary teams to think together about ways to improve efficiency can help mitigate dilemmas of hospital professionals.
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Affiliation(s)
- Ruth Waitzberg
- The Smokler Center for Health Policy Research, Myers-JDC-Brookdale Institute, Jerusalem, Israel
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
| | - Nora Gottlieb
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- Department of Population Medicine and Health Services Research, School of Public Health, Bielefeld University, Bielefeld, Germany
| | - Wilm Quentin
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Reinhard Busse
- Department of Health Care Management, Faculty of Economics & Management, Technical University Berlin, Berlin, Germany
- European Observatory on Health Systems and Policies, Brussels, Belgium
| | - Dan Greenberg
- Department of Health Policy and Management, School of Public Health, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer-Sheva, Israel
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14
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Kreulen RT, Raad M, Musharbash FN, Nayar SK, Best MJ, Puvanesarajah V, Marrache M, Srikumaran U, Wilckens JH. Factors associated with RVU generation in common sports medicine procedures. PHYSICIAN SPORTSMED 2022; 50:233-238. [PMID: 33751911 DOI: 10.1080/00913847.2021.1907258] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Relative value units (RVUs) are integral to the U.S. physician compensation system used by the Centers for Medicare & Medicaid Services. The use of 'work RVUs' (herein, wRVUs) is intended to reimburse physicians according to the amount of expertise and effort needed to safely and effectively perform a procedure. Our purpose was to determine: 1) the number of wRVUs/hour generated by common sports medicine surgical procedures; and 2) how patient characteristics, surgical approach, and practice setting are associated with the number of wRVUs/hour. This analysis was performed to infer whether wRVUs are assigned appropriately according to the factors on which they are purported to be based. METHODS We queried the American College of Surgeons' National Surgical Quality Improvement Program (NSQIP) database for common sports medicine surgical procedures performed in 2018. Data from 19,877 patients (8,258 women) with a mean age of 48 years (range, 18-90) who underwent a surgical sports medicine procedure were analyzed. Work RVUs and operative time were used to calculate work RVUs/hour for each surgical procedure. Univariate and multivariate analyses were used to assess correlations between patient characteristics and wRVUs/hour. RESULTS Knee chondroplasty generated the most mean (± standard deviation) wRVUs/hour at 22 ± 0.5, whereas 'open tenodesis of biceps tendon, long head' generated the least at 9.6 ± 0.25 wRVUs/hour. Factors associated with a greater mean number of wRVUs/hour were younger patient age, female sex, arthroscopic approach, and outpatient setting. Arthroscopic procedures also generated more wRVUs/hour than the same procedures performed through an open approach. wRVUs were not correlated with case complexity or surgical time. CONCLUSION wRVUs/hour in surgical sports medicine procedures vary widely depending on the procedure type, patient characteristics, surgical approach, and practice setting.
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Affiliation(s)
- R Timothy Kreulen
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Micheal Raad
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Farah N Musharbash
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Suresh K Nayar
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Matthew J Best
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Varun Puvanesarajah
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Majd Marrache
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Uma Srikumaran
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - John H Wilckens
- Department of Orthopaedic Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
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15
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High-Impact Health Care. J Ambul Care Manage 2022; 45:140-148. [PMID: 35202031 DOI: 10.1097/jac.0000000000000409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
High-impact health care is a new, employer-driven model that builds on existing employer-direct contracts for primary care centers of excellence and accountable care organizations. High-impact health care proceeds both cautiously and boldly. Cautiously by contracting with providers only after developing relationships with them and assessing their performance-to assure they are top performers; boldly by elevating member feedback to being a top criterion for determining which physicians remain in the network. Driven by the collective purchasing power of large employers, high-impact health care can provide employers a unique path to value-based care.
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Raes S, Trybou J, Annemans L. How to Pay for Telemedicine: A Comparison of Ten Health Systems. Health Syst Reform 2022; 8:2116088. [PMID: 36084277 DOI: 10.1080/23288604.2022.2116088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Telemedicine has the opportunity to improve clinical effectiveness, health care access, cost-savings, and patient care. However, payment systems may form important obstacles to optimally use telemedicine and enable its opportunities. Little is known about payment systems for telemedicine. Therefore, this research aims to increase knowledge on paying for telemedicine by comparing payment systems for telemedicine and identifying similarities and differences. Based on the countries' official physician fee schedules, listing all reimbursed medical services performed by physicians, a comparative analysis of telemedicine payment systems in ten countries was conducted. Findings show that many countries lacked tele-expertise and telemonitoring payment, with the exception for some specific payments such as for telemonitoring in patients with cardiac implantable electronic devices. Moreover, a wide variety of benefit specifications were implemented in all countries to specify which type of clinician contact should be used (remote versus physical) in which circumstances. Payment parity between video and in-person visits was established only in a few countries. Furthermore, fee-for-service was the dominant payment system, although two countries used a capitation-based or hybrid system. The results imply several potential payment challenges when implementing telemedicine: complex benefit specifications, payment parity discussions, and risk of overconsumption due to the dominant fee-for-service system. These challenges appear to be less present in capitation-based or hybrid systems. However, the latter needs to be further explored to harness the full potential of telemedicine.
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Affiliation(s)
- Sarah Raes
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Jeroen Trybou
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Lieven Annemans
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
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17
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Ogundeji YK, Quinn A, Lunney M, Chong C, Chew D, Hopkin G, Senior P, Sumner G, Williams J, Manns B. Optimizing Physician Payment Models to Address Health System Priorities: Perspectives from Specialist Physicians. Healthc Policy 2021; 17:58-72. [PMID: 34543177 PMCID: PMC8437248 DOI: 10.12927/hcpol.2021.26577] [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] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Despite well-documented data on the mixed impact of physician payment models, there is limited evidence on how to enhance existing payment model designs. This study examines the approaches to optimizing payment models from the perspective of specialist physicians to better support patient and physician experience and other health system objectives. METHOD Semi-structured interviews were conducted with 32 specialist physicians across Alberta, Canada. Data from the interviews were analyzed using a framework approach. RESULTS Respondents emphasized the need to incentivize physicians with the right blend of financial and non-financial incentives, including physician wellness. Respondents also highlighted the need for physician involvement and accountability to optimize the value of physician payment models. CONCLUSION To optimize physician payment models, it may be useful to include a blend of financial and non-financial incentives with clear accountability measures as this may better align physician practice with health system priorities.
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Affiliation(s)
- Yewande Kofoworola Ogundeji
- Postdoctoral Fellow, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - Amity Quinn
- Postdoctoral Fellow, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - Meaghan Lunney
- Research Associate, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - Christy Chong
- Research Assistant, Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - Derek Chew
- Research Fellow, Duke Clinical Research Institute, Durham, NC
| | - Gareth Hopkin
- Research Fellow, Institute of Health Economics, Edmonton, AB
| | - Peter Senior
- Professor, Department of Medicine, University of Alberta, Edmonton, AB
| | - Glen Sumner
- Clinical Associate Professor, Department of Cardiovascular Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - Jennifer Williams
- Clinical Associate Professor, Division of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB
| | - Braden Manns
- Professor, Departments of Medicine and Community Health Sciences, O'Brien Institute of Public Health and Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, AB
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Patient Satisfaction with Private Recovery Services and Importance of Physician Behavior during COVID Time. Healthcare (Basel) 2021; 9:healthcare9080928. [PMID: 34442065 PMCID: PMC8394884 DOI: 10.3390/healthcare9080928] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 07/16/2021] [Accepted: 07/20/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction: Patient satisfaction represents an essential indicator of the quality of care in the medical recuperation sector. This study aimed to identify the degree of satisfaction in patients who benefit from medical recuperation services in one private clinic from Romania and the factors that played a part in this respect. Method: An online questionnaire was completed by 105 patients of a private clinic in the period immediately following the opening of the clinic after the quarantine period due to COVID-19. The following concepts were measured: general satisfaction with clinical recuperation services (SG), physician’s behavior (PB), the impact of interventions on the state of health (IHI), modern equipment (ME), and the intention to return to the clinic (IRC). Based on a linear regression model, the impact of PB, IHI, ME, and IRC variables on general satisfaction (SG) was established. Results: The study results confirm the data from studies carried out in different sociocultural contexts in ordinary time, where physician behavior is the most crucial factor in patients’ satisfaction. Therefore, we can say that the physiotherapist’s behavior has an essential role in determining the patients’ satisfaction both in ordinary time and in COVID-19 time. The data in this study reflect the fact that satisfaction with the services offered by a medical recuperation clinic is a predictor for using the services in the future. Still, our study reflects a moderate relationship in intensity.
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The Impact of COVID-19 on the Performance of Primary Health Care Service Providers in a Capitation Payment System: A Case Study from Poland. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18041407. [PMID: 33546467 PMCID: PMC7913620 DOI: 10.3390/ijerph18041407] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Revised: 01/29/2021] [Accepted: 01/31/2021] [Indexed: 11/17/2022]
Abstract
In Poland, as in many other countries, the use of capitation payment schemes in primary health care is popular. Despite this popularity, the subject literature discusses its role in decreasing the quality of primary medical services. This problem is particularly important during COVID-19, when medical entities provide telehealth services to patients. The objective of the study is to examine the effects of COVID-19 pandemic on the performance of the primary health care providers in Poland under a capitation payment scheme. In this study the authors use data from interviews with personnel of medical entities and financial and administrative reports of primary health care providers in order to identify how this crisis situation impacts the performance of primary health care entities, under capitation payment system. The performance indicators include both the financial and quality measures. Selected to the case study primary health care service providers significantly improved their profitability due to considerable costs savings and reduction of services provided to patients in a time of COVID-19 pandemic. Capitation payment system proved to be inefficient, in the studied pandemic period, in terms of the services provided by primary health care service providers to patients and the funds paid to them, in exchange, by the government entities.
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