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Howard SW, Bradford N, Belue R, Henning M, Qian Z, Ahaus K, Reindersma T. Building alternative payment models in health care. FRONTIERS IN HEALTH SERVICES 2024; 4:1235913. [PMID: 38948085 PMCID: PMC11211624 DOI: 10.3389/frhs.2024.1235913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 05/23/2024] [Indexed: 07/02/2024]
Abstract
Introduction Global interest is growing in new value-based models of financing, delivering, and paying for health care services that could produce higher-quality and lower cost outcomes for patients and for society. However, research indicates evidence gaps in knowledge related to alternative payment models (APMs) in early experimentation phases or those contracted between private insurers and their health care provider-partners. The aim of this research was to understand and update the literature related to learning how industry experts design and implement APMs, including specific elements of their models and their choice of stakeholders to be involved in the design and contractual details. Methods A literature review was conducted to guide the research focus and to select themes. The sample was selected using snowball sampling to identify subject matter experts (SMEs). Researchers conducted 16 semi-structured interviews with SMEs in the US, the Netherlands, and Germany in September and October 2021. Interviews were transcribed and using Braun and Clarke's six-phase approach to thematic analysis, researchers independently read, reviewed, and coded participants' responses related to APM design and implementation and subsequently reviewed each other's codes and themes for consistency. Results Participants represented diverse perspectives of the payer, provider, consulting, and government areas of the health care sector. We found design considerations had five overarching themes: (1) population and scope of care and services, (2) benchmarking, metrics, data, and technology; (3) finance, APM type, risk adjustment, incentives, and influencing provider behavior, (4) provider partnerships and the role of physicians, and (5) leadership and regulatory issues. Discussion This study confirmed several of the core components of APM model designs and implementations found in the literature and brought insights on additional aspects not previously emphasized, particularly the role of physicians (especially in leadership) and practice transformation/care processes necessary for providers to thrive under APM models. Importantly, researchers found significant concerns relevant for policymakers about regulations relating to health data sharing, rigid price-setting, and inter-organizational data communication that greatly inhibit the ability to experiment with APMs and those models' abilities to succeed long-term.
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Affiliation(s)
- Steven W. Howard
- Health Services Administration, University of Alabama at Birmingham, Birmingham, AL, United States
| | - Natalie Bradford
- Public Health, University of Texas at San Antonio, San Antonio, TX, United States
| | - Rhonda Belue
- Public Health, University of Texas at San Antonio, San Antonio, TX, United States
| | | | - Zhengmin Qian
- Epidemiology & Biostatistics, Saint Louis University, St. Louis, MO, United States
| | - Kees Ahaus
- Health Services Management & Organization, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Thomas Reindersma
- Health Services Management & Organization, Erasmus University Rotterdam, Rotterdam, Netherlands
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Kimpel CC, Myer EA, Cupples A, Roman Jones J, Seidler KJ, Rick CK, Brown R, Rawlins C, Hadler R, Tsivitse E, Lawlor MAC, Ratcliff A, Holt NR, Callaway-Lane C, Godwin K, Ecker AH. Identifying Barriers and Facilitators to Veterans Affairs Whole Health Integration Using the Updated Consolidated Framework for Implementation Research. J Healthc Qual 2024; 46:137-149. [PMID: 38147581 PMCID: PMC11065588 DOI: 10.1097/jhq.0000000000000419] [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: 12/28/2023]
Abstract
BACKGROUND Veterans Affairs (VA) implemented the Veteran-centered Whole Health System initiative across VA sites with approaches to implementation varying by site. PURPOSE Using the Consolidated Framework for Implementation Research (CFIR), we aimed to synthesize systemic barriers and facilitators to Veteran use with the initiative. Relevance to healthcare quality, systematic comparison of implementation procedures across a national healthcare system provides a comprehensive portrait of strengths and opportunities for improvement. METHODS Advanced fellows from 11 VA Quality Scholars sites performed the initial data collection, and the final report includes CFIR-organized results from six sites. RESULTS Key innovation findings included cost, complexity, offerings, and accessibility. Inner setting barriers and facilitators included relational connections and communication, compatibility, structure and resources, learning centeredness, and information and knowledge access. Finally, results regarding individuals included innovation deliverers, implementation leaders and team, and individual capability, opportunity, and motivation to implement and deliver whole health care. DISCUSSION AND IMPLICATIONS Examination of barriers and facilitators suggest that Whole Health coaches are key components of implementation and help to facilitate communication, relationship building, and knowledge access for Veterans and VA employees. Continuous evaluation and improvement of implementation procedures at each site is also recommended.
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Wang H, Sun H, Fu Y, Cheng W, Jin C, Shi H, Luo Y, Xu X, Wang H. A comprehensive value-based method for new nuclear medical service pricing: with case study of radium [223 Ra] bone metastases treatment. BMC Health Serv Res 2024; 24:397. [PMID: 38553709 PMCID: PMC10981283 DOI: 10.1186/s12913-024-10777-8] [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: 04/12/2023] [Accepted: 02/23/2024] [Indexed: 04/01/2024] Open
Abstract
IMPORTANCE Innovative nuclear medicine services offer substantial clinical value to patients. However, these advancements often come with high costs. Traditional payment strategies do not incentivize medical institutes to provide new services nor determine the fair price for payers. A shift towards a value-based pricing strategy is imperative to address these challenges. Such a strategy would reconcile the cost of innovation with incentives, foster transparent allocation of healthcare resources, and expedite the accessibility of essential medical services. OBJECTIVE This study aims to develop and present a comprehensive, value-based pricing model for new nuclear medicine services, illustrated explicitly through a case study of the radium [223Ra] treatment for bone metastases. In constructing the pricing model, we have considered three primary value determinants: the cost of the new service, associated service risk, and the difficulty of the service provision. Our research can help healthcare leaders design an evidence-based Fee-For-Service (FFS) payment reference pricing with nuclear medicine services and price adjustments. DESIGN, SETTING AND PARTICIPANTS This multi-center study was conducted from March 2021 to February 2022 (including consultation meetings) and employed both qualitative and quantitative methodologies. We organized focus group consultations with physicians from nuclear medicine departments in Beijing, Chongqing, Guangzhou, and Shanghai to standardize the treatment process for radium [223Ra] bone metastases. We used a specially designed 'Radium Nuclide [223Ra] Bone Metastasis Data Collection Form' to gather nationwide resource consumption data to extract information from local databases. Four interviews with groups of experts were conducted to determine the add-up ratio, based on service risk and difficulty. The study organized consultation meeting with key stakeholders, including policymakers, service providers, clinical researchers, and health economists, to finalize the pricing equation and the pricing result of radium [223Ra] bone metastases service. MAIN OUTCOMES AND MEASURES We developed and detailed a pricing equation tailored for innovative services in the nuclear medicine department, illustrating its application through a step-by-step guide. A standardized service process was established to ensure consistency and accuracy. Adhering to best practice guidelines for health cost data analysis, we emphasized the importance of cross-validation of data, where validated data demonstrated less variation. However, it required a more advanced health information system to manage and analyze the data inputs effectively. RESULTS The standardized service of radium [223Ra] bone metastases includes: pre-injection assessment, treatment plan, administration, post-administration monitoring, waste disposal and monitoring. The average duration for each stage is 104 min, 39 min, 25 min, 72 min and 56 min. A standardized monetary value for medical consumables is 54.94 yuan ($7.6), and the standardised monetary value (medical consumables cost plus human input) is 763.68 yuan ($109.9). Applying an agreed value add-up ratio of 1.065, the standardized value is 810.19 yuan ($116.9). Feedback from a consultation meeting with policymakers and health economics researchers indicates a consensus that the pricing equation developed was reasonable and well-grounded. CONCLUSION This research is the first study in the field of nuclear medicine department pricing methodology. We introduce a comprehensive value-based nuclear medical service pricing method and use radium[223Ra] bone metastases treatment pricing in China as a case study. This study establishes a novel pricing framework and provides practical instructions on its implementation in a real-world healthcare setting.
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Affiliation(s)
- Haode Wang
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, S10 2TN, United Kingdom
| | - Hui Sun
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
- National Health Commission Key Laboratory of Health Technology Assessment, School of Public Health, Fudan University, Shanghai, 200032, China
| | - Yuyan Fu
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
| | - Wendi Cheng
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
| | - Chunlin Jin
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
| | - Hongcheng Shi
- Department of Nuclear Medicine, Zhongshan Hospital, Shanghai Medical College, Department of Nuclear Medicine, Shanghai Cancer Center, Fudan University, Shanghai, 200032, China
| | - Yashuang Luo
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China
| | - Xinjie Xu
- School of Rehabilitation Medicine, Shandong University of Traditional Chinese Medicine, Jinan, 250355, China
| | - Haiyin Wang
- Shanghai Health Development Research Center, (Shanghai Medical Information Center), Minhang District, No. 181 Xinbei Road, Shanghai, 201199, People's Republic of China.
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Li X, Teng J, Li X, Lin X, Han Y. The effect of internal salary incentives based on insurance payment on physicians' behavior: experimental evidence. BMC Health Serv Res 2023; 23:1410. [PMID: 38098115 PMCID: PMC10720113 DOI: 10.1186/s12913-023-10408-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 11/30/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Understanding how physicians respond to payment methods is crucial for designing effective incentives and enhancing the insurance system. Previous theoretical research has explored the effects of payment methods on physician behavior based on a two-level incentive path; however, empirical evidence to validate these theoretical frameworks is lacking. To address this research gap, we conducted a laboratory experiment to investigate physicians' behavioral responses to three types of internal salary incentives based on diagnosis-related-group (DRG) and fee-for-service (FFS). METHODS A total of 150 medical students from Capital Medical University were recruited as participants. These subjects played the role of physicians in choosing the quantity of medical services for nine types of patients under three types of salary incentives-fixed wage, constant fixed wage with variable performance wage, and variable fixed wage with variable performance wage, of which performance wage referred to the payment method balance under FFS or DRG. We collected data on the quantities of medical services provided by the participants and analyzed the results using the Friedman test and the fixed effects model. RESULTS The results showed that a fixed wage level did not have a significant impact on physicians' behavior. However, the patients benefited more under the fixed wage compared to other salary incentives. In the case of a floating wage system, which consisted of a constant fixed wage and a variable performance wage from the payment method balance, an increase in performance wage led to a decrease in physicians' service provision under DRG but an increase under FFS. Consequently, this resulted in a decrease in patient benefit. When the salary level remained constant, but the composition of the salary varied, physicians' behavior changed slightly under FFS but not significantly under DRG. Additionally, patient benefits decreased as the ratio of performance wages increased under FFS. CONCLUSIONS While using payment method balance as physicians' salary may be effective in transferring incentives of payment methods to physicians through internal compensation frameworks, it should be used with caution, particularly when the measurement standard of care is imperfect.
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Affiliation(s)
- Xing Li
- School of Public Health, Capital Medical University, No.10 Xitoutiao, Youanmenwai Street, Fengtai District, Beijing, 100069, China
| | - Jiali Teng
- School of Public Health, Capital Medical University, No.10 Xitoutiao, Youanmenwai Street, Fengtai District, Beijing, 100069, China
| | - Xinyan Li
- School of Public Health, Capital Medical University, No.10 Xitoutiao, Youanmenwai Street, Fengtai District, Beijing, 100069, China
| | - Xing Lin
- School of Public Health, Capital Medical University, No.10 Xitoutiao, Youanmenwai Street, Fengtai District, Beijing, 100069, China
| | - Youli Han
- School of Public Health, Capital Medical University, No.10 Xitoutiao, Youanmenwai Street, Fengtai District, Beijing, 100069, China.
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Thornton RLJ, Wilding KM, Gratale D, Walker KO. Alternative Payment Models and Working with Payers-Key Considerations for Advancing Population Health Goals and Achieving Child Health Equity. Pediatr Clin North Am 2023; 70:667-682. [PMID: 37422307 DOI: 10.1016/j.pcl.2023.03.005] [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: 07/10/2023]
Abstract
This article summarizes approaches to achieving value-based care in Pediatrics, providing a framework for understanding the continuum of models from fee-for-service to advanced alternative payment models. We present key examples of how alternative payment models have been developed and applied at the federal level within Medicare through the work of the Centers for Medicare and Medicaid Services (CMS) and the Center for Medicaid and Medicaid Innovation (CMMI). We further describe key lessons learned and opportunities to adapt value-based payment models to promote whole child health and equity. Finally, we summarize policy considerations and challenges in achieving accountability and aligning financial incentives for children's health within a complex payer landscape.
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Affiliation(s)
- Rachel L J Thornton
- Nemours Children's Health, 1201 15th Street Northwest, Suite 520, Wilmington, DE, USA.
| | - Karen M Wilding
- Nemours Children's Health, 1600 Rockland Road, Wilmington, DE 19803, USA
| | - Daniella Gratale
- Nemours Children's Health, 1201 15th Street Northwest, Suite 520, Washington, DC 20005, USA
| | - Kara O Walker
- Nemours Children's Health, 1201 15th Street Northwest, Suite 520, Washington, DC 20005, USA
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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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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: 3] [Impact Index Per Article: 3.0] [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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Gajadien CS, Dohmen PJG, Eijkenaar F, Schut FT, van Raaij EM, Heijink R. Financial risk allocation and provider incentives in hospital-insurer contracts in The Netherlands. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2023; 24:125-138. [PMID: 35412163 PMCID: PMC9002227 DOI: 10.1007/s10198-022-01459-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 03/16/2022] [Indexed: 06/14/2023]
Abstract
In healthcare systems with a purchaser-provider split, contracts are an important tool to define the conditions for the provision of healthcare services. Financial risk allocation can be used in contracts as a mechanism to influence provider behavior and stimulate providers to provide efficient and high-quality care. In this paper, we provide new insights into financial risk allocation between insurers and hospitals in a changing contracting environment. We used unique nationwide data from 901 hospital-insurer contracts in The Netherlands over the years 2013, 2016, and 2018. Based on descriptive and regression analyses, we find that hospitals were exposed to more financial risk over time, although this increase was somewhat counteracted by an increasing use of risk-mitigating measures between 2016 and 2018. It is likely that this trend was heavily influenced by national cost control agreements. In addition, alternative payment models to incentivize value-based health care were rarely used and thus seemingly of lower priority, despite national policies being explicitly directed at this goal. Finally, our analysis shows that hospital and insurer market power were both negatively associated with financial risk for hospitals. This effect becomes stronger if both hospital and insurer have strong market power, which in this case may indicate a greater need to reduce (financial) uncertainties and to create more cooperative relationships.
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Affiliation(s)
- Chandeni S Gajadien
- Dutch Healthcare Authority (Nederlandse Zorgautoriteit; NZa), Utrecht, The Netherlands.
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands.
| | - Peter J G Dohmen
- Dutch Healthcare Authority (Nederlandse Zorgautoriteit; NZa), Utrecht, The Netherlands
- Rotterdam School of Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Frank Eijkenaar
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Frederik T Schut
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Erik M van Raaij
- Rotterdam School of Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, Rotterdam, The Netherlands
| | - Richard Heijink
- The Council of Public Health & Society (Raad voor Volksgezondheid & Samenleving; RVS), The Hague, The Netherlands
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Relative contribution of pharmacists and primary care providers to shared quality measures. EXPLORATORY RESEARCH IN CLINICAL AND SOCIAL PHARMACY 2022; 7:100165. [PMID: 36039373 PMCID: PMC9418985 DOI: 10.1016/j.rcsop.2022.100165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 07/22/2022] [Accepted: 07/28/2022] [Indexed: 12/02/2022] Open
Abstract
Background Alternative payment models are common for both primary care providers and pharmacies. These models rely on quality measures to determine reimbursement, and pharmacists and primary care providers can contribute to performance on a similar set of medication-related measures. Therefore, payers need to decide which provider to incentivize for which measures when both are included in alternative payment models. Objectives To explore the relative contribution of pharmacies and primary care group practices to a range of quality measures. Methods This retrospective cross-sectional study used Medicare Part A, B, and D claims for a 20% random sample of Medicare beneficiaries for 2014–2016. Eight quality measures were selected from the Merit-based Incentive Payment System and Medicare Part D Stars Ratings. Measures included medication adherence measures, appropriate prescribing measures such as high-risk medication use in the elderly, statin use in persons with diabetes (SUPD), and others. The residual intraclass correlation coefficient (RICC) was used to estimate the contribution of pharmacists and primary care providers to measure variation. To estimate the relative contribution across provider types, the pharmacy RICC was divided by the group practice RICC to yield a RICC ratio. Results Due to varying measure eligibility requirements, the number of patients per measure ranged from 179,430 to 2,226,129. Across all measures, the RICC values were low, ranging from 0.013 for SUPD to 0.145 for adult sinusitis. Adherence measures had the highest RICC ratios (1.15–1.44), and the annual influenza vaccination measure had the lowest (0.56). Discussion and conclusions The relative contributions of pharmacists and primary care providers vary across quality measures. As payers design payment models with measures to which pharmacists and primary care providers can contribute, the RICC ratio may be useful in aligning incentives to the providers with the greatest relative contributions. Additional research is needed to validate this method and extend it to additional sets of providers. Comparing RICC ratios across provider groups can guide payer decisions on measures to include in alternative payment models. Absolute RICC values may be useful for inferring measure reliability Pharmacists had greatest relative contributions to adherence measures Primary care providers had greatest relative contributions to non-medication related measures
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Reindersma T, Fabbricotti I, Ahaus K, Sülz S. Integrated Payment, Fragmented Realities? A Discourse Analysis of Integrated Payment in the Netherlands. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19148831. [PMID: 35886684 PMCID: PMC9318584 DOI: 10.3390/ijerph19148831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Revised: 07/13/2022] [Accepted: 07/18/2022] [Indexed: 12/04/2022]
Abstract
The current models used for paying for health and social care are considered a major barrier to integrated care. Despite the implementation of integrated payment schemes proving difficult, such initiatives are still widely pursued. In the Netherlands, this development has led to a payment architecture combining traditional and integrated payment models. To gain insight into the justification for and future viability of integrated payment, this paper’s purpose is to explain the current duality by identifying discourses on integrated payment models, determining which discourses predominate, and how they have changed over time and differ among key stakeholders in healthcare. The discourse analysis revealed four discourses, each with its own underlying assumptions and values regarding integrated payment. First, the Quality-of-Care discourse sees integrated payment as instrumental in improving care. Second, the Affordability discourse emphasizes how integrated payment can contribute to the financial sustainability of the healthcare system. Third, the Bureaucratization discourse highlights the administrative burden associated with integrated payment models. Fourth, the Strategic discourse stresses micropolitical and professional issues that come into play when implementing such models. The future viability of integrated payment depends on how issues reflected in the Bureaucratization and Strategic discourses are addressed without losing sight of quality-of-care and affordability, two aspects attracting significant public interest in The Netherlands.
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Issahaku Y, Thoumi A, Abiiro GA, Ogbouji O, Nonvignon J. Is value-based payment for healthcare feasible under Ghana's National Health Insurance Scheme? Health Res Policy Syst 2021; 19:145. [PMID: 34895235 PMCID: PMC8665306 DOI: 10.1186/s12961-021-00794-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 11/16/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Effective payment mechanisms for healthcare are critical to the quality of care and the efficiency and responsiveness of health systems to meet specific population health needs. Since its inception, Ghana's National Health Insurance Scheme (NHIS) has adopted fee-for-service, diagnostic-related groups and capitation methods, which have contributed to provider reimbursement delays, rising costs and poor quality of care rendered to the scheme's clients. The aim of this study was to explore stakeholder perceptions of the feasibility of value-based payment (VBP) for healthcare in Ghana. Value-based payment refers to a system whereby healthcare providers are paid for the value of services rendered to patients instead of the volume of services. METHODS This study employed a cross-sectional qualitative design. National-level stakeholders were purposively selected for in-depth interviews. The participants included policy-makers (n = 4), implementers (n = 5), public health insurers (n = 3), public and private healthcare providers (n = 7) and civil society organization officers (n = 1). Interviews were audio-recorded and transcribed. Data analysis was performed using both deductive and inductive thematic analysis. The data were analysed using QSR NVivo 12 software. RESULTS Generally, participants perceived VBP to be feasible if certain supporting systems were in place and potential implementation constraints were addressed. Although the concept of VBP was widely accepted, study participants reported that efficient resource management, provider motivation incentives and community empowerment were required to align VBP to the Ghanaian context. Weak electronic information systems and underdeveloped healthcare infrastructure were seen as challenges to the integration of VBP into the Ghanaian health system. Therefore, improvement of existing systems beyond healthcare, including public education, politics, data, finance, regulation, planning, infrastructure and stakeholder attitudes towards VBP, will affect the overall feasibility of VBP in Ghana. CONCLUSION Value-based payment could be a feasible policy option for the NHIS in Ghana if potential implementation challenges such as limited financial and human resources and underdeveloped health system infrastructure are addressed. Governmental support and provider capacity-building are therefore essential for VBP implementation in Ghana. Future feasibility and acceptability studies will need to consider community and patient perspectives.
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Affiliation(s)
- Yussif Issahaku
- Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, Legon, Ghana.,Fuu D/A Junior High School, Ghana Education Service, Fuu, North East Gonja, Ghana
| | - Andrea Thoumi
- Robert J. Margolis, MD, Center for Health Policy, Duke University, 1201 Pennsylvania Ave, NW, Suite 500, Washington DC, 20004, USA.,Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Gilbert Abotisem Abiiro
- Department of Health Services, Policy, Planning, Management and Economics, School of Public Health, University for Development Studies, Tamale, Ghana
| | - Osondu Ogbouji
- Fuu D/A Junior High School, Ghana Education Service, Fuu, North East Gonja, Ghana.,Center for Policy Impact in Global Health, Duke Global Health Institute, Duke University, Durham, NC, USA
| | - Justice Nonvignon
- Department of Health Policy, Planning and Management, School of Public Health, University of Ghana, Legon, Ghana.
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Wise S, Hall J, Haywood P, Khana N, Hossain L, van Gool K. Paying for value: options for value-based payment reform in Australia. AUST HEALTH REV 2021; 46:129-133. [PMID: 34782063 DOI: 10.1071/ah21115] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/26/2021] [Indexed: 11/23/2022]
Abstract
Value-based health care has gained increasing prominence among funders and providers in efforts to improve the outcomes important to patients relative to the resources used to deliver care. In Australia, the value-based healthcare agenda has focused on reducing the use of 'low-value' interventions, redesigning models of care to improve integration between providers and increasing the use of patient-reported measures to drive improvement; all have occurred within existing payment structures. In this paper we describe options for value-based payment reform and highlight two challenges critical for success: attributing financial risk fairly and organisational structures.What is known about the topic?'Fee for service' is the dominant payment method in Australia and creates incentives to increase service volume, rewarding inputs rather than improvements in longer-term health outcomes. There is increasing recognition that payment reform is needed to support the shift to value-based health care in Australia.What does this paper add?This paper describes the three main options for value-based payment reform: episode-based bundled payments chronic condition bundled payments and comprehensive capitation payments. Each involves some degree of funds pooling, and the shifting of risk from the funder to provider to stimulate the more efficient use of resources.What are the implications for practitioners?We conclude that local hospital authorities in the states, private health insurers and primary health networks could implement reform as payment holders, but that capacity development in coordination and risk adjustment will be required. Successful implementation of payment reform will also require investment in data collection and information technology to track patients' care and measure outcomes and costs.
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Affiliation(s)
- Sarah Wise
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, NSW, Australia
| | - Jane Hall
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, NSW, Australia
| | - Philip Haywood
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, NSW, Australia
| | - Nikita Khana
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, NSW, Australia
| | - Lutfun Hossain
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, NSW, Australia
| | - Kees van Gool
- Centre for Health Economics Research and Evaluation, University of Technology Sydney, NSW, Australia
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13
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Zwaagstra Salvado E, van Elten HJ, van Raaij EM. The Linkages Between Reimbursement and Prevention: A Mixed-Methods Approach. Front Public Health 2021; 9:750122. [PMID: 34778183 PMCID: PMC8578935 DOI: 10.3389/fpubh.2021.750122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 09/29/2021] [Indexed: 11/21/2022] Open
Abstract
Background: The benefits of prevention are widely recognized; ranging from avoiding disease onset to substantially reducing disease burden, which is especially relevant considering the increasing prevalence of chronic diseases. However, its delivery has encountered numerous obstacles in healthcare. While healthcare professionals play an important role in stimulating prevention, their behaviors can be influenced by incentives related to reimbursement schemes. Purpose: The purpose of this research is to obtain a detailed description and explanation of how reimbursement schemes specifically impact primary, secondary, tertiary, and quaternary prevention. Methods: Our study takes a mixed-methods approach. Based on a rapid review of the literature, we include and assess 27 studies. Moreover, we conducted semi-structured interviews with eight Dutch healthcare professionals and two representatives of insurance companies, to obtain a deeper understanding of healthcare professionals' behaviors in response to incentives. Results: Nor fee-for-service (FFS) nor salary can be unambiguously linked to higher or lower provision of preventive services. However, results suggest that FFS's widely reported incentive to increase production might work in favor of preventive services such as immunizations but provide less incentives for chronic disease management. Salary's incentive toward prevention will be (partially) determined by provider-organization's characteristics and reimbursement. Pay-for-performance (P4P) is not always necessarily translated into better health outcomes, effective prevention, or adequate chronic disease management. P4P is considered disruptive by professionals and our results expose how it can lead professionals to resort to (over)medicalization in order to achieve targets. Relatively new forms of reimbursement such as population-based payment may incentivize professionals to adapt the delivery of care to facilitate the delivery of some forms of prevention. Conclusion: There is not one reimbursement scheme that will stimulate all levels of prevention. Certain types of reimbursement work well for certain types of preventive care services. A volume incentive could be beneficial for prevention activities that are easy to specify. Population-based capitation can help promote preventive activities that require efforts that are not incentivized under other reimbursements, for instance activities that are not easily specified, such as providing education on lifestyle factors related to a patient's (chronic) disease.
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Affiliation(s)
| | - Hilco J van Elten
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Erik M van Raaij
- Rotterdam School of Management, Erasmus University Rotterdam, Rotterdam, Netherlands.,Erasmus School of Health Policy and Management, Erasmus University Rotterdam, Rotterdam, Netherlands
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14
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Pitkänen LJ, Leskelä RL, Tolkki H, Torkki P. A Value-Based Steering Model for Healthcare. FRONTIERS IN HEALTH SERVICES 2021; 1:709271. [PMID: 36926492 PMCID: PMC10012620 DOI: 10.3389/frhs.2021.709271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022]
Abstract
This article aims to answer how a commissioning body can steer health services based on value in an environment where the commissioner is responsible for the health services of a population with varying health service needs. In this design science study, we constructed a value-based steering model consisting of three parts: (1) the principles of steering; (2) the steering process; and (3) Value Steering Canvas, a concrete tool for steering. The study is based on Finland, a tax-funded healthcare system, where healthcare is a public service. The results can be applied in any system where there is a commissioner and a service provider, whether they are two separate organizations or not. We conclude that steering can be done based on value. The commissioning body can start using value-based steering without changes in legislation or in the present service system. Further research is needed to test the model in practice.
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Affiliation(s)
- Laura J Pitkänen
- Department of Public Health, Faculty of Medicine, University of Helsinki, Helsinki, Finland
| | | | - Helena Tolkki
- Nordic Healthcare Group, Helsinki, Finland.,Faculty of Management and Business, Tampere University, Tampere, Finland
| | - Paulus Torkki
- Department of Public Health, Faculty of Medicine, University of Helsinki, Helsinki, Finland
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15
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Cattel D, Eijkenaar F. Value-Based Provider Payment Initiatives Combining Global Payments With Explicit Quality Incentives: A Systematic Review. Med Care Res Rev 2020; 77:511-537. [PMID: 31216945 PMCID: PMC7536531 DOI: 10.1177/1077558719856775] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2018] [Accepted: 05/20/2019] [Indexed: 01/17/2023]
Abstract
An essential element in the pursuit of value-based health care is provider payment reform. This article aims to identify and analyze payment initiatives comprising a specific manifestation of value-based payment reform that can be expected to contribute to value in a broad sense: (a) global base payments combined with (b) explicit quality incentives. We conducted a systematic review of the literature, consulting four scientific bibliographic databases, reference lists, the Internet, and experts. We included and compared 18 initiatives described in 111 articles/documents on key design features and impact on value. The initiatives are heterogeneous regarding the operationalization of the two payment components and associated design features. Main commonalities between initiatives are a strong emphasis on primary care, the use of "virtual" spending targets, and the application of risk adjustment and other risk-mitigating measures. Evaluated initiatives generally show promising results in terms of lower spending growth with equal or improved quality.
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16
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de Korte MH, Verhoeven GS, Elissen AMJ, Metzelthin SF, Ruwaard D, Mikkers MC. Using machine learning to assess the predictive potential of standardized nursing data for home healthcare case-mix classification. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2020; 21:1121-1129. [PMID: 32601992 PMCID: PMC7561562 DOI: 10.1007/s10198-020-01213-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 06/19/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND The Netherlands is currently investigating the feasibility of moving from fee-for-service to prospective payments for home healthcare, which would require a suitable case-mix system. In 2017, health insurers mandated a preliminary case-mix system as a first step towards generating information on client differences in relation to care use. Home healthcare providers have also increasingly adopted standardized nursing terminology (SNT) as part of their electronic health records (EHRs), providing novel data for predictive modelling. OBJECTIVE To explore the predictive potential of SNT data for improvement of the existing preliminary Dutch case-mix classification for home healthcare utilization. METHODS We extracted client-level data from the EHRs of a large home healthcare provider, including data from the existing Dutch case-mix system, SNT data (specifically, NANDA-I) and the hours of home healthcare provided. We evaluated the predictive accuracy of the case-mix system and the SNT data separately, and combined, using the machine learning algorithm Random Forest. RESULTS The case-mix system had a predictive performance of 22.4% cross-validated R-squared and 6.2% cross-validated Cumming's Prediction Measure (CPM). Adding SNT data led to a substantial relative improvement in predicting home healthcare hours, yielding 32.1% R-squared and 15.4% CPM. DISCUSSION The existing preliminary Dutch case-mix system distinguishes client needs to some degree, but not sufficiently. The results indicate that routinely collected SNT data contain sufficient additional predictive value to warrant further research for use in case-mix system design.
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Affiliation(s)
- Maud H. de Korte
- Dutch Healthcare Authority (NZa), Utrecht, The Netherlands
- Department of Economics, Tilburg University, Tilburg, The Netherlands
| | - Gertjan S. Verhoeven
- Dutch Healthcare Authority (NZa), Utrecht, The Netherlands
- Department of Economics, Tilburg University, Tilburg, The Netherlands
| | - Arianne M. J. Elissen
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Silke F. Metzelthin
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Dirk Ruwaard
- Department of Health Services Research, Care and Public Health Research Institute (CAPHRI), Faculty of Health, Medicine and Life Sciences, Maastricht University, Maastricht, The Netherlands
| | - Misja C. Mikkers
- Dutch Healthcare Authority (NZa), Utrecht, The Netherlands
- Department of Economics, Tilburg University, Tilburg, The Netherlands
- Tilburg Law and Economics Center (TILEC), Tilburg University, Tilburg, The Netherlands
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17
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Feng Y, Kristensen SR, Lorgelly P, Meacock R, Sanchez MR, Siciliani L, Sutton M. Pay for performance for specialised care in England: Strengths and weaknesses. Health Policy 2019; 123:1036-1041. [PMID: 31405615 DOI: 10.1016/j.healthpol.2019.07.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2018] [Revised: 05/29/2019] [Accepted: 07/09/2019] [Indexed: 11/25/2022]
Abstract
Pay-for-Performance (P4P) schemes have become increasingly common internationally, yet evidence of their effectiveness remains ambiguous. P4P has been widely used in England for over a decade both in primary and secondary care. A prominent P4P programme in secondary care is the Commissioning for Quality and Innovation (CQUIN) framework. The most recent addition to this framework is Prescribed Specialised Services (PSS) CQUIN, introduced into the NHS in England in 2013. This study offers a review and critique of the PSS CQUIN scheme for specialised care. A key feature of PSS CQUIN is that whilst it is centrally developed, performance targets are agreed locally. This means that there is variation across providers in the schemes selected from the national menu, the achievement level needed to earn payment, and the proportion of the overall payment attached to each scheme. Specific schemes vary in terms of what is incentivised - structure, process and/or outcome - and how they are incentivised. Centralised versus decentralised decision making, the nature of the performance measures, the tiered payment structure and the dynamic nature of the schemes have created a sophisticated but complex P4P programme which requires evaluation to understand the effect of such incentives on specialised care.
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Affiliation(s)
- Yan Feng
- Centre for Primary Care and Public Health, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, E1 2AB, London, UK
| | - Søren Rud Kristensen
- Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, SW7 2A, London, UK
| | - Paula Lorgelly
- Office of Health Economics, SW1E 6QT, London, UK; Faculty of Life Sciences and Medicine, King's College London, WC2R 2LS, London, UK
| | - Rachel Meacock
- School of Health Sciences, University of Manchester, M13 9PL, Manchester, UK
| | | | - Luigi Siciliani
- Department of Economics and Related Studies, University of York, YO10 5DD, York, UK.
| | - Matt Sutton
- School of Health Sciences, University of Manchester, M13 9PL, Manchester, UK
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