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Matias MA, Jacobs R, Aragón MJ, Fernandes L, Gutacker N, Siddiqi N, Kasteridis P. Assessing the uptake of incentivised physical health checks for people with serious mental illness: a cohort study in primary care. Br J Gen Pract 2024; 74:e449-e455. [PMID: 38914479 PMCID: PMC11221420 DOI: 10.3399/bjgp.2023.0532] [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] [Accepted: 01/29/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND People with serious mental illness are more likely to experience physical illnesses. The onset of many of these illnesses can be prevented if detected early. Physical health screening for people with serious mental illness is incentivised in primary care in England through the Quality and Outcomes Framework (QOF). GPs are paid to conduct annual physical health checks on patients with serious mental illness, including checks of body mass index (BMI), cholesterol, and alcohol consumption. AIM To assess the impact of removing and reintroducing QOF financial incentives on uptake of three physical health checks (BMI, cholesterol, and alcohol consumption) for patients with serious mental illness. DESIGN AND SETTING Cohort study using UK primary care data from the Clinical Practice Research Datalink between April 2011 and March 2020. METHOD A difference-in-difference analysis was employed to compare differences in the uptake of physical health checks before and after the intervention, accounting for relevant observed and unobserved confounders. RESULTS An immediate change was found in uptake after physical health checks were removed from, and after they were added back to, the QOF list. For BMI, cholesterol, and alcohol checks, the overall impact of removal was a reduction in uptake of 14.3, 6.8, and 11.9 percentage points, respectively. The reintroduction of BMI screening in the QOF increased the uptake by 10.2 percentage points. CONCLUSION This analysis supports the hypothesis that QOF incentives lead to better uptake of physical health checks.
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Affiliation(s)
| | - Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
| | - María José Aragón
- Centre for Health Economics, University of York, York, UK; HCD Economics, Las Palmas de Gran Canaria, Spain
| | - Luis Fernandes
- Centre for Health Economics, University of York, York, UK; Janssen Pharmaceutica NV, Beerse, Belgium
| | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK; Hull York Medical School, York, UK; Bradford District Care NHS Foundation Trust, Bradford, UK
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Leao DLL, Cremers HP, van Veghel D, Pavlova M, Hafkamp FJ, Groot WNJ. Facilitating and Inhibiting Factors in the Design, Implementation, and Applicability of Value-Based Payment Models: A Systematic Literature Review. Med Care Res Rev 2023; 80:467-483. [PMID: 36951451 PMCID: PMC10469482 DOI: 10.1177/10775587231160920] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 02/08/2023] [Indexed: 03/24/2023]
Abstract
Evidence on the potential for value-based payment models to improve quality of care and ensure more efficient outcomes is limited and mixed. We aim to identify the factors that enhance or inhibit the design, implementation, and application of these models through a systematic literature review. We used the PRISMA guidelines. The facilitating and inhibiting factors were divided into subcategories according to a theoretical framework. We included 143 publications, each reporting multiple factors. Facilitators on objectives and strategies, such as realistic/achievable targets, are reported in 56 studies. Barriers regarding dedicated time and resources (e.g., an excessive amount of time for improvements to manifest) are reported in 25 studies. Consensus within the network regarding objectives and strategies, trust, and good coordination is essential. Health care staff needs to be kept motivated, well-informed, and actively involved. In addition, stakeholders should manage expectations regarding when results are expected to be achieved.
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Tano M, Paubel P, Ribault M, Degrassat-Théas A. What About Offering a Financial Incentive Directly to Clinical Units to Encourage the Use of Biosimilars? Results of a Two-Year National Experiment in France. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2023; 21:799-811. [PMID: 37253898 PMCID: PMC10228890 DOI: 10.1007/s40258-023-00812-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 06/01/2023]
Abstract
BACKGROUND Regarding the low penetration of biosimilars in the French market, in 2018, the government introduced two mutually exclusive financial incentives to increase biosimilar use. They redirect 20% (general case) or 30% (experimental case) of the price difference between the reference product and its biosimilar to hospitals for every biosimilar delivered in retail pharmacies from these hospital prescriptions. The experimental case specifically targets prescribing clinical units. OBJECTIVES Our study aimed to assess whether the new payment scheme closer to physicians (experimental case) improved etanercept biosimilar penetration after 25 months. METHOD We evaluated hospital prescriptions using IQVIA Xponent data. The monthly number of etanercept boxes delivered in retail pharmacies was linked to the corresponding hospital prescription. The impact of the experimental case on the etanercept biosimilar rate was assessed by a difference-in-difference method. RESULTS Among the 39 hospitals studied in the experimental case compared with the 169 belonging to the general case, a similar growing trend of etanercept biosimilar use was observed before October 2018. At the start of the experiment, there was an acceleration of biosimilar penetration in the experimental group, until both groups reached a plateau. A significant double difference estimator of 9.72 percentage points in favor of the experiment confirmed this (p < 2.2.10-16). CONCLUSION The French experimental incentive appeared to be more effective at increasing biosimilar use. As it is expected to be implemented in all hospitals, the knowledge gained during this testing phase should allow adjustment of some of its terms and increase physician engagement.
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Affiliation(s)
- Marion Tano
- General Agency of Equipment and Health Products (AGEPS), Assistance Publique-Hôpitaux de Paris (AP-HP), 7, Rue du Fer à Moulin, 75005 Paris Cedex, France
- Health Law and Health Economics Department, Faculty of Pharmacy, Paris University, Université Paris Cité, 4 Avenue de l’Observatoire, 75006 Paris, France
- Health Law Institute, Inserm, UMR S 1145, Paris University, Université Paris Cité, 45 Rue des Saints-Pères, 75270 Paris Cedex 6, France
| | - Pascal Paubel
- General Agency of Equipment and Health Products (AGEPS), Assistance Publique-Hôpitaux de Paris (AP-HP), 7, Rue du Fer à Moulin, 75005 Paris Cedex, France
- Health Law and Health Economics Department, Faculty of Pharmacy, Paris University, Université Paris Cité, 4 Avenue de l’Observatoire, 75006 Paris, France
- Health Law Institute, Inserm, UMR S 1145, Paris University, Université Paris Cité, 45 Rue des Saints-Pères, 75270 Paris Cedex 6, France
| | - Matthieu Ribault
- General Agency of Equipment and Health Products (AGEPS), Assistance Publique-Hôpitaux de Paris (AP-HP), 7, Rue du Fer à Moulin, 75005 Paris Cedex, France
| | - Albane Degrassat-Théas
- General Agency of Equipment and Health Products (AGEPS), Assistance Publique-Hôpitaux de Paris (AP-HP), 7, Rue du Fer à Moulin, 75005 Paris Cedex, France
- Health Law and Health Economics Department, Faculty of Pharmacy, Paris University, Université Paris Cité, 4 Avenue de l’Observatoire, 75006 Paris, France
- Health Law Institute, Inserm, UMR S 1145, Paris University, Université Paris Cité, 45 Rue des Saints-Pères, 75270 Paris Cedex 6, France
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Aggarwal M, Hutchison B, Kokorelias KM, Mehta K, Greenberg L, Moran K, Barber D, Samson K. Impact of remuneration, extrinsic and intrinsic incentives on interprofessional primary care teams: protocol for a rapid scoping review. BMJ Open 2023; 13:e072076. [PMID: 37336539 DOI: 10.1136/bmjopen-2023-072076] [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: 06/21/2023] Open
Abstract
INTRODUCTION Interprofessional teams and funding and payment provider arrangements are key attributes of high-performing primary care. Several Canadian jurisdictions have introduced team-based models with different payment models. Despite these investments, the evidence of impact is mixed. This has raised questions about whether team-based primary care models are being implemented to facilitate team collaboration and effectiveness. Thus, we present a protocol for a rapid scoping review to systematically map, synthesise and summarise the existing literature on the impact of provider remuneration mechanisms and extrinsic and intrinsic incentives in team-based primary care. This review will answer three research questions: (1) What is the impact of provider remuneration models on team, patient, provider and system outcomes in primary care?; (2) What extrinsic and intrinsic incentives have been used in interprofessional primary care teams?; and (3) What is the impact of extrinsic and intrinsic team-based incentives on team, patient, provider and system outcomes? METHODS AND ANALYSIS We will conduct a rapid scoping review in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines. We will search electronic databases (Medline, Embase, CINAHL, PsycINFO, EconLit) and grey literature sources (Google Scholar, Google). This review will consider all empirical studies and full-text English-language articles published between 2000 and 2022. Reviewers will independently perform the literature search, data extraction and synthesis of included studies. The Mixed Methods Appraisal Tool will be used to appraise the quality of evidence. The literature will be synthesised, summarised and mapped to themes that answer the research question of this review. ETHICS AND DISSEMINATION Ethics approval is not required. Findings from this study will be written for publication in an open-access peer-review journal and presented at national and international conferences. Knowledge users are part of the research team and will assist with disseminating findings to the public, clinicians, funders and professional associations.
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Affiliation(s)
- Monica Aggarwal
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Brian Hutchison
- Department of Family Medicine, Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Kristina Marie Kokorelias
- Department of Geriatric Medicine, Sinai Health and University Health Network, Toronto, Ontario, Canada
- Rehabiliation Sciences Institute and Department of Occupational Therapy and Occupational Sciences, University of Toronto Temerty Faculty of Medicine, Toronto, Ontario, Canada
| | - Kavita Mehta
- Association of Family Health Teams of Ontario, Toronto, Ontario, Canada
| | | | - Kimberly Moran
- Ontario College of Family Physicians, Toronto, Ontario, Canada
| | - David Barber
- Department of Family Medicine, Queen's University, Kingston, Ontario, Canada
| | - Kevin Samson
- East Wellington Family Health Team, Erin/Rockwood, Ontario, Canada
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Morales DR, Minchin M, Kontopantelis E, Roland M, Sutton M, Guthrie B. Estimated impact from the withdrawal of primary care financial incentives on selected indicators of quality of care in Scotland: controlled interrupted time series analysis. BMJ 2023; 380:e072098. [PMID: 36948515 PMCID: PMC10031759 DOI: 10.1136/bmj-2022-072098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/24/2023]
Abstract
OBJECTIVE To determine whether the withdrawal of the Quality and Outcomes Framework (QOF) scheme in primary care in Scotland in 2016 had an impact on selected recorded quality of care, compared with England where the scheme continued. DESIGN Controlled interrupted time series regression analysis. SETTING General practices in Scotland and England. PARTICIPANTS 979 practices with 5 599 171 registered patients in Scotland, and 7921 practices with 56 270 628 registered patients in England in 2013-14, decreasing to 864 practices in Scotland and 6873 in England in 2018-19, mainly due to practice mergers. MAIN OUTCOME MEASURES Changes in quality of care at one year and three years after withdrawal of QOF financial incentives in Scotland at the end of the 2015-16 financial year for 16 indicators (two complex processes, nine intermediate outcomes, and five treatments) measured annually for financial years from 2013-14 to 2018-19. RESULTS A significant decrease in performance was observed for 12 of the 16 quality of care indicators in Scotland one year after QOF was abolished and for 10 of the 16 indicators three years after QOF was abolished, compared with England. At three years, the absolute percentage point difference between Scotland and England was largest for recording (by tick box) of mental health care planning (-40.2 percentage points, 95% confidence interval -45.5 to -35.0) and diabetic foot screening (-22.8, -33.9 to -11.7). Substantial reductions were, however, also observed for intermediate outcomes, including blood pressure control in patients with peripheral arterial disease (-18.5, -22.1 to -14.9), stroke or transient ischaemic attack (-16.6, -20.6 to -12.7), hypertension (-13.7, -19.4 to -7.9), diabetes (-12.7, -15.0 to -12.4), or coronary heart disease (-12.8, -14.9 to -10.8), and for glycated haemoglobin control in people with HbA1c levels ≤75 mmol/mol (-5.0, -8.4 to -1.5). No significant differences were observed between Scotland and England for influenza immunisation and antiplatelet or anticoagulant treatment for coronary heart disease three years after withdrawal of incentives. CONCLUSION The abolition of financial incentives in Scotland was associated with reductions in recorded quality of care for most performance indicators. Changes to pay for performance should be carefully designed and implemented to monitor and respond to any reductions in care quality.
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Affiliation(s)
- Daniel R Morales
- Division of Population Health and Genomics, University of Dundee, UK
| | - Mark Minchin
- National Institute for Health and Care Excellence, Centre for Guidelines, Manchester, UK
| | - Evangelos Kontopantelis
- Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, UK
| | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Matt Sutton
- Division of Population Health, Health Services Research and Primary Care, University of Manchester, Manchester, UK
| | - Bruce Guthrie
- Advanced Care Research Centre, Usher Institute, University of Edinburgh, Edinburgh, UK
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Bramwell D, Hotham S, Peckham S, Checkland K, Forbes LJL. Evaluation of the introduction of QOF quality improvement modules in English general practice: early findings from a rapid, qualitative exploration of implementation. BMJ Open Qual 2022; 11:bmjoq-2022-001960. [PMID: 36162934 PMCID: PMC9516148 DOI: 10.1136/bmjoq-2022-001960] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 08/25/2022] [Indexed: 11/21/2022] Open
Abstract
Background A 2018 review of the English primary care pay-for-performance scheme, the Quality and Outcomes Framework, suggested that it should evolve to better support holistic, patient-centred care and leadership for quality improvement (QI). From 2019, as part of the vision of change, financially incentivised QI cycles (initially in prescribing safety and end-of-life care), were introduced into the scheme. Objectives To conduct a rapid evaluation of general practice staff attitudes, experiences and plans in relation to the implementation of the first two QI modules. This study was commissioned by NHS England and will inform development of the QI programme. Methods Semistructured telephone interviews were conducted with 25 practice managers from a range of practices across England. Interviews were audio recorded with consent and transcribed verbatim. Anonymised data were reflexively thematically analysed using the framework method of analysis to identify common themes across the interviews. Results Participants reported broadly favourable views of incentivised QI, suggesting the prescribing safety module was easier to implement than the end-of-life module. Additional staff time needed and challenges of reviewing activities with other practices were reported as concerns. Some highlighted that local flexibility and influence on subject matter may improve the effectiveness of QI. Several questioned the choices of topic, recognising greater need and potential for improving quality of care in other clinical areas. Conclusion Practices supported the idea of financial incentivisation of QI, however, it will be important to ensure that focus on QI cycles in specific clinical areas does not have unintended effects. A key issue will be keeping up momentum with the introduction of new modules each year which are time consuming to carry out for time poor General Practitioners (GPs)/practices.
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Affiliation(s)
- Donna Bramwell
- Centre for Primary Care and Health Services Research, Health Organisation, Policy and Economics (HOPE) Group, University of Manchester, Manchester, UK
| | - Sarah Hotham
- Centre for Health Services Studies, University of Kent, Canterbury, UK
| | - Stephen Peckham
- Centre for Health Services Studies, University of Kent, Canterbury, UK
- Department of Health Services and Policy Research, London School of Hygiene and Tropical Medicine, London, UK
| | - Kath Checkland
- Centre for Primary Care and Health Services Research, Health Organisation, Policy and Economics (HOPE) Group, University of Manchester, Manchester, UK
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Incentivizing appropriate prescribing in primary care: Development and first results of an electronic health record-based pay-for-performance scheme. Health Policy 2022; 126:1010-1017. [PMID: 35870964 DOI: 10.1016/j.healthpol.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 04/29/2022] [Accepted: 07/13/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Part of the funding of Dutch General Practitioners (GPs) care is based on pay-for-performance, including an incentive for appropriate prescribing according to guidelines in national formularies. Aim of this paper is to describe the development of an indicator and an infrastructure based on prescription data from GP Electronic Health Records (EHR), to assess the level of adherence to formularies and the effects of the pay-for-performance scheme, thereby assessing the usefulness of the infrastructure and the indicator. METHODS Adherence to formularies was calculated as the percentage of first prescriptions by the GP for medications that were included in one of the national formularies used by the GP, based on prescription data from EHRs. Adherence scores were collected quarterly for 2018 and 2019 and subsequently sent to health insurance companies for the pay-for-performance scheme. Adherence scores were used to monitor the effect of the pay-for-performance scheme. RESULTS 75% (2018) and 83% (2019) of all GP practicesparticipated. Adherence to formularies was around 85% or 95%, depending on the formulary used. Adherence improved significantly, especially for practices that scored lowest in 2018. DISCUSSION We found high levels of adherence to national formularies, with small improvements after one year. The infrastructure will be used to further stimulate formulary-based prescribing by implementing more actionable and relevant indicators on adherence scores for GPs.
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Giancotti M, Mauro M, Rania F. Exploring the effectiveness of a P4P scheme from the perspective of Italian general practitioners: A replication study. Int J Health Plann Manage 2022; 37:1526-1544. [DOI: 10.1002/hpm.3417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 12/08/2021] [Accepted: 01/03/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Monica Giancotti
- Department of Clinical and Experimental Medicine Magna Graecia University of Catanzaro Catanzaro Italy
| | - Marianna Mauro
- Department of Clinical and Experimental Medicine Magna Graecia University of Catanzaro Catanzaro Italy
| | - Francesco Rania
- Department of Law, Economics and Sociology Magna Graecia University of Catanzaro Catanzaro Italy
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The impact of removing financial incentives and/or audit and feedback on chlamydia testing in general practice: A cluster randomised controlled trial (ACCEPt-able). PLoS Med 2022; 19:e1003858. [PMID: 34982767 PMCID: PMC8726492 DOI: 10.1371/journal.pmed.1003858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 11/02/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Financial incentives and audit/feedback are widely used in primary care to influence clinician behaviour and increase quality of care. While observational data suggest a decline in quality when these interventions are stopped, their removal has not been evaluated in a randomised controlled trial (RCT), to our knowledge. This trial aimed to determine whether chlamydia testing in general practice is sustained when financial incentives and/or audit/feedback are removed. METHODS AND FINDINGS We undertook a 2 × 2 factorial cluster RCT in 60 general practices in 4 Australian states targeting 49,525 patients aged 16-29 years for annual chlamydia testing. Clinics were recruited between July 2014 and September 2015 and were followed for up to 2 years or until 31 December 2016. Clinics were eligible if they were in the intervention group of a previous cluster RCT where general practitioners (GPs) received financial incentives (AU$5-AU$8) for each chlamydia test and quarterly audit/feedback reports of their chlamydia testing rates. Clinics were randomised into 1 of 4 groups: incentives removed but audit/feedback retained (group A), audit/feedback removed but incentives retained (group B), both removed (group C), or both retained (group D). The primary outcome was the annual chlamydia testing rate among 16- to 29-year-old patients, where the numerator was the number who had at least 1 chlamydia test within 12 months and the denominator was the number who had at least 1 consultation during the same 12 months. We undertook a factorial analysis in which we investigated the effects of removal versus retention of incentives (groups A + C versus groups B + D) and the effects of removal versus retention of audit/feedback (group B + C versus groups A + D) separately. Of 60 clinics, 59 were randomised and 55 (91.7%) provided data (group A: 15 clinics, 11,196 patients; group B: 14, 11,944; group C: 13, 11,566; group D: 13, 14,819). Annual testing decreased from 20.2% to 11.7% (difference -8.8%; 95% CI -10.5% to -7.0%) in clinics with incentives removed and decreased from 20.6% to 14.3% (difference -7.1%; 95% CI -9.6% to -4.7%) where incentives were retained. The adjusted absolute difference in treatment effect was -0.9% (95% CI -3.5% to 1.7%; p = 0.2267). Annual testing decreased from 21.0% to 11.6% (difference -9.5%; 95% CI -11.7% to -7.4%) in clinics where audit/feedback was removed and decreased from 19.9% to 14.5% (difference -6.4%; 95% CI -8.6% to -4.2%) where audit/feedback was retained. The adjusted absolute difference in treatment effect was -2.6% (95% CI -5.4% to -0.1%; p = 0.0336). Study limitations included an unexpected reduction in testing across all groups impacting statistical power, loss of 4 clinics after randomisation, and inclusion of rural clinics only. CONCLUSIONS Audit/feedback is more effective than financial incentives of AU$5-AU$8 per chlamydia test at sustaining GP chlamydia testing practices over time in Australian general practice. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12614000595617.
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Cabreira FDS, Hugo FN, Celeste RK. Pay-for-performance and dental procedures: A longitudinal analysis of the Brazilian Program for the Improvement of Access and Quality of Dental Specialities Centres. Community Dent Oral Epidemiol 2021; 50:4-10. [PMID: 34967967 DOI: 10.1111/cdoe.12717] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 10/21/2021] [Accepted: 11/30/2021] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Evaluate the impact of a pay-for-performance program on changes in the number of dental procedures performed by public secondary dental care services in Brazil. METHODS A longitudinal study was carried out with 932 public Dental Specialities Centres (Centro de Especialidades Odontológicas - CEO) that participated in the pay-for-performance Program for the Improvement of Access and Quality of Dental Specialities Centres Services (PMAQ/CEO) and 379 non-CEO centres with secondary dental production. The non-CEO and a group of CEOs did not receive financial incentives from the PMAQ-CEO and served as control groups. Three CEOs groups received additional financial incentives of 20%, 60% or 100% over maintenance values, based on their performance scores. The outcome was the increase (yes/no) in the number of dental procedures between 2011/2013 and 2015/2017. Analyses were carried out using logistic regressions. RESULTS The number of specialized procedures increased in 48.4% of the services, 44.6% among non-CEO, 52.3% among CEO with no financial incentive and 59.1% among CEO with 100% incentive. The fully adjusted model showed that CEOs receiving 100% of the financial incentive had greater odds of increasing the production of dental procedures (OR = 1.65, 95%CI: 1.09-2.51). Services that increased the number of specialist dentists had (OR = 2.35, 95%CI 1.88-2.94). Municipalities that increased in coverage of private dental insurance had OR = 0.98 (95%CI: 0.94-1.02), and those with higher coverage of primary dental care had OR = 1.02 (95%CI: 0.99-1.05). CONCLUSION Pay-for-performance may increase the production of dental procedures by CEOs, and mechanisms explaining it must be further investigated.
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Affiliation(s)
- Fabiana da Silva Cabreira
- Department of Preventive and Social Dentistry, School of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil.,Federal Institute of Education, Science and Technology Farroupilha - IFFar, Alegrete, Brazil.,Prefeitura Municipal de Alegrete, Alegrete, Brazil
| | - Fernando Neves Hugo
- Department of Preventive and Social Dentistry, School of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Roger Keller Celeste
- Department of Preventive and Social Dentistry, School of Dentistry, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Li C, Zhou Y, Zhou C, Lai J, Fu J, Wu Y. Perceptions of nurses and physicians on pay-for-performance in hospital: a systematic review of qualitative studies. J Nurs Manag 2021; 30:521-534. [PMID: 34747079 DOI: 10.1111/jonm.13505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/30/2021] [Accepted: 11/04/2021] [Indexed: 11/29/2022]
Abstract
AIMS To systematically examine perceptions of nurses and physicians on pay-for-performance in hospital. BACKGROUND Pay-for-performance projects have proliferated over the past two decades, most systematic reviews of which solely focused on its effectiveness in primary healthcare and the physicians' or nurses' attitudes. However, systematic reviews of qualitative approaches for better examining perceptions of both nurses and physicians in hospital are lacking. EVALUATION Electronic databases were systematic searched with date from its inception to December 31, 2020. Meta-aggregation synthesis methodology and the conceptual framework of the Theory of Planned Behavior were used to summarize findings. KEY ISSUES A total of nine studies were included. Three major synthesized themes were identified: (1) perceptions of the motivation effects and positive outcomes (2) perceptions about the design defects and negative effects (3) perceptions of the obstacles in the implementation process. CONCLUSION To maximize the intended positive effects, nurses' and physicians' perceptions should be considered and incorporated into the project design and implementation stage. IMPLICATIONS FOR NURSING MANAGEMENT AND RESEARCH The paper gives enlightenment to nurse managers on improving and advancing the cause of nurses when planning for or evaluating their institutions' policies on pay-for-performance in the future research.
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Affiliation(s)
- Chaixiu Li
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China.,School of Nursing, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Yanni Zhou
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Chunlan Zhou
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Jie Lai
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China.,School of Nursing, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Jiaqi Fu
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China.,School of Nursing, Southern Medical University, Guangzhou City, Guangdong Province, China
| | - Yanni Wu
- Nanfang Hospital, Southern Medical University, Guangzhou City, Guangdong Province, China
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Role of financial incentives in family planning services in India: a qualitative study. BMC Health Serv Res 2021; 21:905. [PMID: 34479545 PMCID: PMC8414850 DOI: 10.1186/s12913-021-06799-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 07/19/2021] [Indexed: 11/29/2022] Open
Abstract
Background In an effort to encourage Family Planning (FP) adoption, since 1952, the Government of India has been implementing various centrally sponsored schemes that offer financial incentives (FIs) to acceptors as well as service providers, for services related to certain FP methods. However, understanding of the role of FIs on uptake of FP services, and the quality of FP services provided, is limited and mixed. Methods A qualitative descriptive study was conducted in Chatra and Palamu districts of Jharkhand state. A total of 64 interviews involving multiple stakeholders were conducted. The stakeholders included recent FP acceptors or clients, FP service providers of public health facilities including Accredited Social Healthcare Activists (ASHAs), government health officials managing FP programs at the district and state level, and members of development partners supporting FP programs in Jharkhand. Data analysis included both inductive and deductive strategies. It was done using the software Atlas ti version 8. Results It has emerged that there is a strong felt need for FP among majority of the clients, and FIs may be a motivator for uptake of FP methods only among those belonging to the lower socio economic strata. For ASHAs, FI is the primary motivator for providing FP related services. There may be a tendency among them and the nurses to promote methods which have more financial incentives linked with them. There are mixed opinions on discontinuing FIs for clients or replacing them with non-financial incentives. Delays in payment of FIs to both clients and the ASHAs is a common issue and adversely effects the program. Conclusion FIs for clients have limited influence on their decision to take up a FP method while different amounts of FIs for ASHAs and nurses, linked with different FP methods, may be influencing their service provision. More research is needed to determine the effect of discontinuing FI for FP services. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06799-1.
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Veen A, Bartram T, Cooke FL. Potential, challenges and pitfalls of pay-for-performance schemes: a narrative review evaluating the merits for the Australian home care sector. J Health Organ Manag 2021; ahead-of-print. [PMID: 34406719 DOI: 10.1108/jhom-01-2020-0013] [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: 11/17/2022]
Abstract
PURPOSE This qualitative narrative review aims to identify and evaluate the potential, challenges and pitfalls of pay-for-performance (P4P) schemes for the home care of adults with a disability. Due to a limited experimentation with P4P schemes in the context of the home and disability care sectors, the authors conducted a narrative review focusing on related areas of care, primarily nursing home care, to better understand the effectiveness of P4P schemes as a care intervention and evaluate the challenges associated with the introduction of these schemes. DESIGN/METHODOLOGY/APPROACH The authors employed a narrative review approach to examine the effectiveness of P4P schemes as a care intervention. The approach included a manual content analysis of the relevant academic and grey literature, focusing on the potential, challenges and pitfalls of P4P for care funders and providers. FINDINGS There is some, albeit limited, evidence from other related areas of care to support the effectiveness of P4P to improve the quality of care or the efficiency of its delivery for the home care sector. The results of prior studies are, however, often mixed and inconclusive, due to flaws with the design of schemes, including the nature of the incentives. Limited duration and poor-quality evaluations have further hampered the ability of studies to demonstrate the effectiveness of P4P schemes, which diminishes the credibility of these care interventions. When undertaken systematically, there seems to be some evidence that P4P can work; however, it requires careful design, implementation, measurement and evaluation. PRACTICAL IMPLICATIONS Based on the challenges associated with the successful implementation of P4P schemes, the authors identified lessons for the design, implementation, measurement and evaluation of P4P schemes for care funders and policymakers. ORIGINALITY/VALUE This study critically evaluates the potential of P4P as a care intervention for the home care and disability sectors. By evaluating the potential, challenges and pitfalls associated with P4P in related areas of care, the study provides guidance to home care funders, providers and policymakers in care settings.
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Affiliation(s)
- Alex Veen
- University of Sydney SDN, Sydney, Australia
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Davis MT, Torres M, Nguyen A, Stewart M, Reif S. Improving quality and performance in substance use treatment programs: What is being done and why is it so hard? JOURNAL OF SOCIAL WORK (LONDON, ENGLAND) 2021; 21:141-161. [PMID: 33746611 PMCID: PMC7971453 DOI: 10.1177/1468017319867834] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
SUMMARY As states plan to implement system-wide change of any kind, it is important to understand program directors' perspectives on challenges they face. This is especially true with quality improvement reforms. Much research has focused on quality improvement in medicine, but there is a gap in our knowledge about programs that treat individuals with drug or alcohol use. From 2007 to 2016, Maine contracted with selected substance use treatment programs using financial incentives to improve quality, with focus on treatment access, engagement, retention, and completion as measures of quality. Using surveys and in-depth interviews, this research documents strategies that programs used to improve performance and challenges faced in implementing reforms. Only programs that received federal block grant funding through the state to provide substance use treatment were eligible for an incentive contract, creating a natural experiment with non-block grant programs (non-incentive). Directors were interviewed in incentive (n=13) and non-incentive programs (n=12). FINDINGS Thematic analysis revealed that: 1) programs focused on QI, but those eligible for incentives focused on different quality measures, 2) most of the reforms in both groups targeted improving treatment access and retention, and 3) programs faced substantial challenges in undertaking reforms. Despite efforts, many programs could not meet quality measures consistently over time and faced barriers over which they had little control. APPLICATIONS Policy makers and program administrators will benefit from knowing the challenges of undertaking QI initiatives and provide support for the programs.
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Affiliation(s)
- Margot T Davis
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Maria Torres
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA
- Smith College School for Social Work, Northampton, MA
| | - AnMarie Nguyen
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Maureen Stewart
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Sharon Reif
- Institute for Behavioral Health, Heller School for Social Policy and Management, Brandeis University, Waltham, MA
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Prang KH, Maritz R, Sabanovic H, Dunt D, Kelaher M. Mechanisms and impact of public reporting on physicians and hospitals' performance: A systematic review (2000-2020). PLoS One 2021; 16:e0247297. [PMID: 33626055 PMCID: PMC7904172 DOI: 10.1371/journal.pone.0247297] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/04/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Public performance reporting (PPR) of physician and hospital data aims to improve health outcomes by promoting quality improvement and informing consumer choice. However, previous studies have demonstrated inconsistent effects of PPR, potentially due to the various PPR characteristics examined. The aim of this study was to undertake a systematic review of the impact and mechanisms (selection and change), by which PPR exerts its influence. METHODS Studies published between 2000 and 2020 were retrieved from five databases and eight reviews. Data extraction, quality assessment and synthesis were conducted. Studies were categorised into: user and provider responses to PPR and impact of PPR on quality of care. RESULTS Forty-five studies were identified: 24 on user and provider responses to PPR, 14 on impact of PPR on quality of care, and seven on both. Most of the studies reported positive effects of PPR on the selection of providers by patients, purchasers and providers, quality improvement activities in primary care clinics and hospitals, clinical outcomes and patient experiences. CONCLUSIONS The findings provide moderate level of evidence to support the role of PPR in stimulating quality improvement activities, informing consumer choice and improving clinical outcomes. There was some evidence to demonstrate a relationship between PPR and patient experience. The effects of PPR varied across clinical areas which may be related to the type of indicators, level of data reported and the mode of dissemination. It is important to ensure that the design and implementation of PPR considered the perspectives of different users and the health system in which PPR operates in. There is a need to account for factors such as the structural characteristics and culture of the hospitals that could influence the uptake of PPR.
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Affiliation(s)
- Khic-Houy Prang
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
| | - Roxanne Maritz
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
- Rehabilitation Services and Care Unit, Swiss Paraplegic Research, Nottwil, Switzerland
- Department of Health Sciences and Health Policy, University of Lucerne, Lucerne, Switzerland
| | - Hana Sabanovic
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
| | - David Dunt
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
| | - Margaret Kelaher
- Centre for Health Policy, Melbourne School of Population and Global Health, The University of Melbourne, Carlton, Australia
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Wu YF, Chen MY, Chen TH, Wang PC, Peng YS, Lin MS. The effect of pay-for-performance program on infection events and mortality rate in diabetic patients: a nationwide population-based cohort study. BMC Health Serv Res 2021; 21:78. [PMID: 33478477 PMCID: PMC7818736 DOI: 10.1186/s12913-021-06091-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 01/14/2021] [Indexed: 01/14/2023] Open
Abstract
Background Diabetes mellitus is a known risk factor for infection. Pay for Performance (P4P) program is designed to enhance the comprehensive patient care. The aim of this study is to evaluate the effect of the P4P program on infection incidence in type 2 diabetic patients. Methods This is a retrospective longitudinal cohort study using data from the National Health Insurance Research Database in Taiwan. Diabetic patients between 1 January 2002 and 31 December 2013 were included. Primary outcomes analyzed were patient emergency room (ER) infection events and deaths. Results After propensity score matching, there were 337,184 patients in both the P4P and non-P4P cohort. The results showed that patients’ completing one-year P4P program was associated with a decreased risk of any ER infection event (27.2% vs. 29%; subdistribution hazard ratio [HR] 0.87, 95% confidence interval [CI] 0.86–0.88). While the number needed to treat was 58 for the non-P4P group, it dropped to 28 in the P4P group. The risk of infection-related death was significantly lower in the P4P group than in the non-P4P group (4.1% vs. 7.6%; HR 0.46, 95% CI 0.45–0.47). The effect of P4P on ER infection incidence and infection-related death was more apparent in the subgroups of patients who were female, had diabetes duration ≥5 years, chronic kidney disease, higher Charlson’s Comorbidity Index scores and infection-related hospitalization in the previous 3 years. Conclusions The P4P program might reduce risk of ER infection events and infection-related deaths in type 2 diabetic patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-06091-2.
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Affiliation(s)
- Yi-Fang Wu
- Department of Emergency Medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Mei-Yen Chen
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan.,Department of Nursing, Chang Gung University, Taoyuan, Taiwan
| | - Tien-Hsing Chen
- Department of Cardiology, Chang Gung Memorial Hospital, Keelung, Taiwan.,Biostatistical Consultation Center of Chang Gung Memorial Hospital, Keelung, Taiwan Community Medicine Research Center of Chang Gung Memorial Hospital, Keelung, Taiwan.,Chang Gung University, Taoyuan, Taiwan
| | - Po-Chang Wang
- Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Yun-Shing Peng
- Department of Endocrinology and Metabolism, Department of internal medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
| | - Ming-Shyan Lin
- Department of Nursing, Chang Gung University of Science and Technology, Chiayi, Taiwan. .,Department of Cardiology, Chang Gung Memorial Hospital, Chiayi, Taiwan. .,Graduate Institute of Clinical Medical Sciences, College of Medicine, Chang Gung University, Taoyuan, Taiwan.
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Can Asia provide models for tax-based European health systems? A comparative study of Singapore and Sweden. HEALTH ECONOMICS POLICY AND LAW 2020; 17:157-174. [PMID: 33190673 DOI: 10.1017/s1744133120000390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Singapore's health system generates similar levels of health outcomes as does Sweden's but for only 4.4% rather than 11.0% of gross domestic product, with Singapore's resulting health sector savings being re-directed to help fund both long-term care and retirement pensions for its elderly citizens. This paper contrasts the framework of financial risk-sharing and the configuration and management of health service providers in these two high-income, small-population countries. Two main institutional distinctions emerge from this country case comparison: (1) Key differences exist in the practical configuration of solidarity for payment of health care services, reflecting differing cultural roots and social expectations, which in turn carry substantial implications for financing long-term care and pensions. (2) Differing arrangements exist in the organization of health service institutions, in particular balancing public as against private sector responsibilities for owning, operating and managing these two countries' respective hospitals. These different structural characteristics generate fundamental differences in health sector financial and delivery outcomes in one developed country in Far East Asia as compared with a well-respected tax-funded health system in Western Europe. In the post-COVID era, as Western European policymakers find themselves forced to adjust their publicly funded health systems to (further) reductions in economic growth rates and overall tax receipts, and as the cost of the information revolution continues to rise while efforts to fund better coordinated social and home care services for growing numbers of chronically ill elderly remain inadequate, this two-country case comparison highlights a series of health system design questions that could potentially provide alternative health sector financing and service delivery strategies.
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Martin B, Jones J, Miller M, Johnson-Koenke R. Health Care Professionals' Perceptions of Pay-for-Performance in Practice: A Qualitative Metasynthesis. INQUIRY: The Journal of Health Care Organization, Provision, and Financing 2020; 57:46958020917491. [PMID: 32448014 PMCID: PMC7249558 DOI: 10.1177/0046958020917491] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Incentive-based pay-for-performance (P4P) models have been introduced during the
last 2 decades as a mechanism to improve the delivery of evidence-based care
that ensures clinical quality and improves health outcomes. There is mixed
evidence that P4P has a positive effect on health outcomes and researchers cite
lack of engagement from health care professionals as a limiting factor. This
qualitative metasynthesis of existing qualitative research was conducted to
integrate health care professionals’ perceptions of P4P in clinical practice.
Four themes emerged during the research process: positive perceptions of the
value of performance measurement and associated financial incentives; negative
perceptions of the performance measurement and associated financial incentives;
perceptions of how P4P programs influence the quality/appropriateness of care;
and perceptions of the influence of P4P program on professional roles and
workplace dynamics. Identifying factors that influence health care
professionals’ perceptions about this type of value-based payment model will
guide future research.
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Affiliation(s)
| | | | - Matthew Miller
- University of Colorado, Aurora, USA.,VA Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, USA
| | - Rachel Johnson-Koenke
- University of Colorado, Aurora, USA.,Rocky Mountain Regional VA Medical Center, Denver, CO, USA
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Early Performance of Hospital Value-based Purchasing Program in Medicare: A Systematic Review. Med Care 2020; 58:734-743. [PMID: 32692140 DOI: 10.1097/mlr.0000000000001354] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Under the Affordable Care Act, the Centers for Medicare and Medicaid Services has greatly expanded inpatient fee-for-value programs including the Hospital Value-based Purchasing (HVBP) program. Existing evidence from the HVBP program is mixed. There is a need for a systematic review of the HVBP program to inform discussions on how to improve the program's effectiveness. OBJECTIVE To review and summarize studies that evaluated the HVBP program's impact on clinical processes, patient satisfaction, costs and outcomes, or assessed hospital characteristics associated with performance on the program. DESIGN We searched the MEDLINE/PubMed, Scopus, ProQuest database for literature published between January 2013 and July 2019 using the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. RESULTS Of 988 studies reviewed, 33 studies that met the selection criteria were included. A small group of studies (n=7) evaluated the impact of the HVBP program, and no impact on processes or patient outcomes was reported. None of the included studies evaluated the effect of HVBP program on health care costs. Other studies (n=28) evaluated the hospital characteristics associated with HVBP performance, suggesting that safety-net hospitals reportedly performed worse on several quality and cost measures. Other hospital characteristics' associations with performance were unclear. CONCLUSIONS Our findings suggest that the current HVBP does not lead to meaningful improvements in quality of care or patient outcomes and may negatively affect safety-net hospitals. More rigorous and comprehensive adjustment is needed for more valid hospital comparisons.
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Costigan J, Feldman SS, Lemak M. Assessment of Patient Satisfaction With Dermatology Clinics According to Clinic Type: Mixed Methods Study. JMIR DERMATOLOGY 2020. [DOI: 10.2196/17171] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background
Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey responses are considered significant indicators of the quality of care and patient satisfaction. There is a pressing need to improve patient satisfaction rates as CAHPS survey responses are considered when determining the amount a facility will be reimbursed by the Centers of Medicare and Medicaid each year. Low overall CAHPS scores for an academic medical center’s dermatology clinics were anecdotally attributed to clinic type. However, it was unclear whether clinic type was contributing to the low scores or whether there were other factors.
Objective
This study aimed to determine where the efforts of patient satisfaction improvement should be focused for two different types of dermatology clinics (private and rapid access clinics).
Methods
This study used a concurrent mixed methods design. Secondary data derived from the University of Alabama at Birmingham Hospital’s Press Ganey website were analyzed for clinic type comparisons and unstructured data were qualitatively analyzed to further enrich the quantitative findings. The University of Alabama at Birmingham Hospital is an academic medical center. The data were analyzed to determine the contributors responsible for each clinic not meeting national benchmarks. Thereafter, a review of these contributing factors was further performed to assess the difference in CAHPS scores between the private and rapid access clinics to determine if clinic type was a contributing factor to the overall scores.
Results
The data sample included 821 responses from May 2017 to May 2018. Overall, when both private clinics and rapid access clinics were viewed collectively, majority of the patients reported stewardship of patient resources as the most poorly rated factor (367/549, 66.8%) and physician communication quality as the most positively rated factor (581/638, 91.0%). However, when private clinics and rapid access clinics were viewed individually, rapid access clinics contributed slightly to the overall lower dermatology scores at the academic medical center.
Conclusions
This study determined that different factors were responsible for lower CAHPS scores for the two different dermatology clinics. Some of the contributing factors were associated with the mission of the clinic. It was suspected that the mission had not been properly communicated to patients, leading to misaligned expectations of care at each clinic.
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Wadhera RK, Bhatt DL, Kind AJ, Song Y, Williams KA, Maddox TM, Yeh RW, Dong L, Doros G, Turchin A, Maddox KEJ. Association of Outpatient Practice-Level Socioeconomic Disadvantage With Quality of Care and Outcomes Among Older Adults With Coronary Artery Disease: Implications for Value-Based Payment. Circ Cardiovasc Qual Outcomes 2020; 13:e005977. [PMID: 32228065 PMCID: PMC7259485 DOI: 10.1161/circoutcomes.119.005977] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Medicare patients with coronary artery disease (CAD) have been a significant focus of value-based payment programs for outpatient practices. Physicians and policymakers, however, have voiced concern that value-based payment programs may penalize practices that serve vulnerable populations. This study evaluated whether outpatient practices that serve socioeconomically disadvantaged populations have worse CAD outcomes, and if this reflects the delivery of lower-quality care or rather, patient and community factors beyond the care provided by physician practices. METHODS AND RESULTS Retrospective cohort study of Medicare fee-for-service patients ≥65 years with CAD at outpatient practices participating in the the Practice Innovation and Clinical Excellence registry from January 1, 2010 to January 1, 2015. Outpatient practices were stratified into quintiles by the proportion of most disadvantaged patients-defined by an area deprivation score in the highest 20% nationally-served at each practice site. Prescription of guideline recommended therapies for CAD as well as clinical outcomes (emergency department presentation for chest pain, hospital admission for unstable angina or acute myocardial infarction [AMI], 30-day readmission after AMI, and 30-day mortality after AMI) were evaluated by practice-level socioeconomic disadvantage with hierarchical logistic regression models, using practices serving the fewest socioeconomically disadvantaged patients as a reference. The study included 453 783 Medicare fee-for-service patients ≥65 years of age with CAD (mean [SD] age, 75.3 [7.7] years; 39.7% female) cared for at 271 outpatient practices. At practices serving the highest proportion of socioeconomically disadvantaged patients (group 5), compared with practices serving the lowest proportion (group 1), there was no significant difference in the likelihood of prescription of antiplatelet therapy (odds ratio [OR], 0.94 [95% CI, 0.69-1.27]), β-blocker therapy if prior myocardial infarction or left ventricular ejection fraction <40% (OR, 0.97 [95% CI, 0.69-1.35]), ACE (angiotensin-converting enzyme) inhibitor or angiotensin receptor blocker if left ventricular ejection fraction <40% and/or diabetes mellitus (OR, 0.93 [95% CI, 0.74-1.19]), statin therapy (OR, 0.88 [95% CI, 0.68-1.14]), or cardiac rehabilitation (OR, 0.45 [95% CI, 0.20-1.00]). Patients cared for at the most disadvantaged-serving practices (group 5) were more likely to be admitted for unstable angina (adjusted OR, 1.46 [95% CI, 1.04-2.05]). There was no significant difference in the likelihood of emergency department presentation for chest pain or hospital admission for AMI between practices. Thirty day mortality rates after AMI were higher among patients at the most disadvantaged-serving practices (aOR, 1.31 [95% CI, 1.02-1.68]), but 30-day readmission rates did not differ. All associations were attenuated after additional adjustment for patient-level area deprivation index. CONCLUSIONS Physician outpatient practices that serve the most socioeconomically disadvantaged patients with CAD perform worse on some clinical outcomes, despite providing similar guideline-recommended care as other practices, and consequently could fare poorly under value-based payment programs. Social factors beyond care provided by outpatient practices may partly explain worse outcomes. Policymakers should consider accounting for socioeconomic disadvantage in value-based payment programs initiatives that target outpatient practices.
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Affiliation(s)
- Rishi K. Wadhera
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
| | - Deepak L. Bhatt
- Brigham and Women’s Hospital Heart & Vascular Center, Harvard Medical School, Boston, MA
| | - Amy J.H. Kind
- Geriatrics Division, Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin
| | - Yang Song
- Baim Institute for Clinical Research, Boston, MA
| | - Kim A. Williams
- Division of Cardiology, Department of Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Thomas M. Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
| | - Robert W. Yeh
- Richard and Susan Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Beth Israel Deaconess Medical and Harvard Medical School, Boston, MA
| | - Liyan Dong
- Baim Institute for Clinical Research, Boston, MA
| | - Gheorghe Doros
- Baim Institute for Clinical Research, Boston, MA
- Department of Biostatistics, Boston University, Boston, MA
| | - Alexander Turchin
- Baim Institute for Clinical Research, Boston, MA
- Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Karen E. Joynt Maddox
- Cardiovascular Division, Department of Medicine, Washington University School of Medicine, Saint Louis, MO
- Center for Health Economics and Policy, Institute for Public Health at Washington University, Saint Louis, MO
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Waddimba AC, Mohr DC, Beckman HB, Meterko MM. Physicians' perceptions of autonomy support during transition to value-based reimbursement: A multi-center psychometric evaluation of six-item and three-item measures. PLoS One 2020; 15:e0230907. [PMID: 32236139 PMCID: PMC7112234 DOI: 10.1371/journal.pone.0230907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2019] [Accepted: 03/12/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Successive health system reforms have steadily eroded physician autonomy. Escalating accountability demands placed on physicians concurrent with diminishing autonomy plus widespread "cost cutting" endanger clinical work-life quality and, in turn, threaten patient-care quality, safety, and continuity. This has engendered a renewed emphasis on bettering physician work-life to safeguard patient care. Research indicates that autonomy support could be an effective intervention point in this dynamic, and that improving healthcare practitioners' experience of autonomy can promote better patient outcomes. New measures of autonomy support towards physicians during systemic/organizational transformation are thus needed. OBJECTIVE We investigated the validity and reliability of two versions of a brief measure of physicians' perceptions of autonomy support. DESIGN Psychometric evaluation of practitioners' responses to a theory-based, pilot-tested, multi-center, cross-sectional survey-questionnaire. PARTICIPANTS Physicians serving in California, Massachusetts, or upstate New York clinical practices implementing pay-for-performance incentives were eligible. We obtained responses from 1,534 (35.14%) of 4,365 physicians surveyed. ANALYSIS We randomly partitioned the study sample equitably into derivation and validation subsamples. We conducted parallel analysis, inter-item/point-biserial correlations, and item-response-theory-based graded response modeling on six autonomy support items. Three items with the highest (a) point-biserial correlations, (b) item-level discrimination and (c) information capture were used to construct a short-form (3-item) version of the full (6-item) autonomy scale. We utilized exploratory structural equation modeling and confirmatory factor analysis to establish the factor structure and construct validity of the full-length and short-form scales before comparing their factor invariance, reliability and interrater agreement across physician subgroups. FINDINGS All six autonomy support items loaded highly onto one factor accounting for the majority of variance and demonstrating good data fit. The three most discriminating and informative items loaded equally well onto a single factor with similar goodness-of-fit to the data. The three-item scale correlated highly with its six-item parent, showing equally high sensitivity and specificity in discriminating high autonomy support. Variability in scores nested predominantly at within- rather than between-subgroup levels. CONCLUSIONS AND IMPLICATIONS Our data supported the factor structure, construct validity, internal consistency, and reliability of six- and three-item autonomy support scales. These brief tools are easily incorporated into multi-dimensional questionnaires at relatively low cost.
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Affiliation(s)
- Anthony C Waddimba
- Baylor Scott and White Research Institute, Dallas, Texas, United States of America
- Department of Surgery, Health Systems Science, Baylor University Medical Center, Dallas, Texas, United States of America
| | - David C Mohr
- Center for Healthcare Organization and Implementation Research (CHOIR), VA Boston Healthcare System, Boston, Massachusetts, United States of America
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
| | - Howard B Beckman
- Departments of Family Medicine, Internal Medicine & Public Health Sciences, University of Rochester School of Medicine and Dentistry, Rochester, New York, United States of America
- Common Ground Health, Rochester, New York, United States of America
| | - Mark M Meterko
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Performance Measurement, VA Office of Analytics and Business Intelligence (OABI), Washington, D.C., United States of America
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Abstract
Mylène Lagarde, Luis Huicho, and Irene Papanicolas discuss different strategies policy makers can use to motivate health providers in order to improve quality of care
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Affiliation(s)
- Mylène Lagarde
- Department of Health Policy, London School of Economics, London, UK
| | - Luis Huicho
- Centro de Investigación en Salud Materna e Infantil and Centro de Investigación para el Desarrollo Integral y Sostenible, Universidad Peruana Cayetano Heredia, Lima, Peru
| | - Irene Papanicolas
- Department of Health Policy, London School of Economics, London, UK
- Department of Health Policy and Management, Harvard T H Chan School of Public Health, Boston, MA, USA
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Ahluwalia SC, Damberg CL, Haas A, Shekelle PG. How are medical groups identified as high-performing? The effect of different approaches to classification of performance. BMC Health Serv Res 2019; 19:500. [PMID: 31319830 PMCID: PMC6639957 DOI: 10.1186/s12913-019-4293-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 06/23/2019] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Payers and policy makers across the international healthcare market are increasingly using publicly available summary measures to designate providers as "high-performing", but no consistently-applied approach exists to identifying high performers. This paper uses publicly available data to examine how different classification approaches influence which providers are designated as "high-performers". METHODS We conducted a quantitative analysis of cross-sectional publicly-available performance data in the U.S. We used 2014 Minnesota Community Measurement data from 58 medical groups to classify performance across 4 domains: quality (two process measures of cancer screening and 2 composite measures of chronic disease management), total cost of care, access (a composite CAHPS measure), and patient experience (3 CAHPS measures). We classified medical groups based on performance using either relative thresholds or absolute values of performance on all included measures. RESULTS Using relative thresholds, none of the 58 medical groups achieved performance in the top 25% or 35% in all 4 performance domains. A relative threshold of 40% was needed before one group was classified as high-performing in all 4 domains. Using absolute threshold values, two medical groups were classified as high-performing across all 4 domains. In both approaches, designating "high performance" using fewer domains led to more groups designated as high-performers, though there was little to moderate concordance across identified "high-performing" groups. CONCLUSIONS Classification of medical groups as high performing is sensitive to the domains of performance included, the classification approach, and choice of threshold. With increasing focus on achieving high performance in healthcare delivery, the absence of a consistently-applied approach to identify high performers impedes efforts to reliably compare, select and reward high-performing providers.
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Affiliation(s)
- Sangeeta C. Ahluwalia
- RAND Corporation, 1776 Main Street, Santa Monica, CA 91403 USA
- UCLA Fielding School of Public Health, Los Angeles, CA USA
| | | | - Ann Haas
- RAND Corporation, Pittsburgh, PA USA
| | - Paul G. Shekelle
- RAND Corporation, 1776 Main Street, Santa Monica, CA 91403 USA
- VA West Los Angeles Medical Center, Los Angeles, CA USA
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Job satisfaction and guideline adherence among physicians: Moderating effects of perceived autonomy support and job control. Soc Sci Med 2019; 233:208-217. [DOI: 10.1016/j.socscimed.2019.04.045] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Revised: 04/25/2019] [Accepted: 04/29/2019] [Indexed: 12/21/2022]
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Liao CH, Lu N, Tang CH, Chang HC, Huang KC. Assessing the relationship between healthcare market competition and medical care quality under Taiwan's National Health Insurance programme. Eur J Public Health 2019; 28:1005-1011. [PMID: 29873710 DOI: 10.1093/eurpub/cky099] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background There is still significant uncertainty as to whether market competition raises or lowers clinical quality in publicly funded healthcare systems. We attempted to assess the effects of market competition on inpatient care quality of stroke patients in a retrospective study of the universal single-payer health insurance system in Taiwan. Methods In this 11-year population-based study, we conducted a pooled time-series cross-sectional analysis with a fixed-effects model and the Hausman test approach by utilizing two nationwide datasets: the National Health Insurance Research Database and the National Hospital and Services Survey in Taiwan. Patients who were admitted to a hospital for ischemic or hemorrhagic stroke were enrolled. After excluding patients with a previous history of stroke and those with different types of stroke, 247 379 ischemic and 79 741 hemorrhagic stroke patients were included in our analysis. Four outcome indicators were applied: the in-hospital mortality rate, 30-day post-operative complication rate, 14-day re-admission rate and 30-day re-admission rate. Results Market competition exerted a negative or negligible effect on the medical care quality of stroke patients. Compared to hospitals located in a highly competitive market, in-hospital mortality rates for hemorrhagic stroke patients were significantly lower in moderately (β = -0.05, P < 0.01) and less competitive markets (β = -0.05, P < 0.01). Conversely, the impact of market competition on the quality of care of ischemic stroke patients was insignificant. Conclusions Simply fostering market competition might not achieve the objective of improving the quality of health care. Other health policy actions need to be contemplated.
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Affiliation(s)
- Chih-Hsien Liao
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan.,The Institute of Health Policy and Management, College of Public Health, National Taiwan University, Taipei, Taiwan
| | - Ning Lu
- Department of Health Administration, College of Health and Human Services, Governors State University, University Park, IL, USA
| | - Chao-Hsiun Tang
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Hui-Chih Chang
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
| | - Kuo-Cherh Huang
- School of Health Care Administration, College of Management, Taipei Medical University, Taipei, Taiwan
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Girault A, Gervès-Pinquié C, Moisdon JC, Minvielle É. [Entre dynamique d'amélioration de la qualité des soins et conformisme administratif : comportements des établissements de santé français face au paiement à la performance (P4P)]. ACTA ACUST UNITED AC 2019; 14:78-92. [PMID: 31017867 PMCID: PMC7008690 DOI: 10.12927/hcpol.2019.25791] [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] [Indexed: 11/16/2022]
Abstract
Le paiement à la performance (P4P) continue de se développer dans les systèmes de santé des pays industrialisés, malgré des preuves encore assez limitées de son efficacité. Cette étude propose de comprendre le comportement des établissements de santé face à ce nouveau mode de paiement en se basant sur l'expérimentation de P4P hospitalier conduite en France. Nous avons, pour cela, combiné une approche quantitative basée sur un questionnaire auprès des établissements participants et une analyse qualitative dans neuf établissements afin de mieux identifier les processus à l'œuvre. L'étude montre que des actions correctives ont été réalisées dans certains établissements mais que les effets du programme sur l'organisation restent en fait assez limités puisqu'ils s'opèrent davantage à la marge. Les comportements semblent être essentiellement le reflet d'une volonté de conformation des organisations aux attentes de la tutelle, sans transformations organisationnelles majeures. Il sera toutefois intéressant de voir comment des perceptions différentes structurent ces comportements sur le long terme.
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Affiliation(s)
- Anne Girault
- Ingénieure d'études, Chaire de recherche « Prospective en Santé » - EHESP /MNH-BFMRattachée à l'équipe « Management des Organisations de Santé (EA 7348) »École des Hautes Études en Santé PubliqueParis, France
| | - Chloé Gervès-Pinquié
- Économiste, Institut de recherche en santé respiratoire des Pays de la LoireAngers, France
| | - Jean-Claude Moisdon
- Chercheur associé à l'équipe « Management des Organisations de Santé (EA 7348) »École des Hautes Études en Santé Publique Paris, France
| | - Étienne Minvielle
- Directeur de l'équipe de recherche « Management des Organisations de Santé (EA 7348) »École des Hautes Études en Santé PubliqueParis, France
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Vlaanderen FP, Tanke MA, Bloem BR, Faber MJ, Eijkenaar F, Schut FT, Jeurissen PPT. Design and effects of outcome-based payment models in healthcare: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:217-232. [PMID: 29974285 PMCID: PMC6438941 DOI: 10.1007/s10198-018-0989-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 06/22/2018] [Indexed: 05/23/2023]
Abstract
INTRODUCTION Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects. METHODS We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs. RESULTS We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth. DISCUSSION Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.
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Affiliation(s)
- F P Vlaanderen
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands.
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands.
| | - M A Tanke
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands
| | - B R Bloem
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Department of Neurology, Radboudumc, Nijmegen, The Netherlands
| | - M J Faber
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Radboudumc, Nijmegen, The Netherlands
| | - F Eijkenaar
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - F T Schut
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Erasmus School of Health Policy and Management, Erasmus University, Rotterdam, The Netherlands
| | - P P T Jeurissen
- Radboudumc, Geert Grooteplein Zuid 10, 6525 GA, Nijmegen, The Netherlands
- Scientific Institute for Quality of Healthcare (IQ Healthcare), Celsus Academy for Sustainable Healthcare, Radboudumc, Nijmegen, The Netherlands
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Rudasingwa M, Uwizeye MR. Physicians' and nurses' attitudes towards performance-based financial incentives in Burundi: a qualitative study in the province of Gitega. Glob Health Action 2018; 10:1270813. [PMID: 28452651 PMCID: PMC5328346 DOI: 10.1080/16549716.2017.1270813] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Performance-based financing (PBF) was first implemented in Burundi in 2006 as a pilot programme in three provinces and was rolled out nationwide in 2010. PBF is a reform approach to improve the quality, quantity, and equity of health services and aims at achieving universal health coverage. It focuses on how to best motivate health practitioners. Objective: To elicit physicians’ and nurses’ experiences and views on how PBF influenced and helped them in healthcare delivery. Methods: A qualitative cross-sectional study was carried out among frontline health workers such as physicians and nurses. The data was gathered through individual face-to-face, in-depth, semi-structured interviews with 6 physicians and 30 nurses from February to March 2011 in three hospitals in Gitega Province. A simple framework approach and thematic analysis using a combination of manual technique and MAXQDA software guided the analysis of the interview data. Results: Overall, the interviewees felt that the PBF scheme had provided positive motivation to improve the quality of care, mainly in the structures and process of care. The utilization of health services and the relationship between health practitioners and patients also improved. The salary top-ups were recognized as the most significant impetus to increase effort in improving the quality of care. The small and sometimes delayed financial incentives paid to physicians and nurses were criticized. The findings of this study also indicate that the positive interaction between performance-based incentive schemes and other health policies is crucial in achieving comprehensive improvement in healthcare delivery. Conclusions: PBF has the potential to motivate medical staff to improve healthcare provision. The views of medical staff and the context of the area of implementation have to be taken into consideration when designing and implementing PBF schemes.
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Affiliation(s)
- Martin Rudasingwa
- a Institute of Health Economics and Clinical Epidemiology, University Hospital of Cologne, Faculty of Medicine , University of Cologne , Cologne , Germany
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Minchin M, Roland M, Richardson J, Rowark S, Guthrie B. Quality of Care in the United Kingdom after Removal of Financial Incentives. N Engl J Med 2018; 379:948-957. [PMID: 30184445 DOI: 10.1056/nejmsa1801495] [Citation(s) in RCA: 89] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The benefits of pay-for-performance schemes in improving the quality of care remain uncertain. There is little information on the effect of removing incentives from existing pay-for-performance schemes. METHODS We conducted interrupted time-series analyses of electronic medical record (EMR) data from 2010 to 2017 for 12 quality-of-care indicators in the United Kingdom's Quality and Outcomes Framework for which financial incentives were removed in 2014 and 6 indicators for which incentives were maintained. We estimated the effects of removing incentives on changes in performance on quality-of-care measures. RESULTS Complete longitudinal data were available for 2819 English primary care practices with more than 20 million registered patients. There were immediate reductions in documented quality of care for all 12 indicators in the first year after the removal of financial incentives. Reductions were greatest for indicators related to health advice, with a reduction of 62.3 percentage points (95% confidence interval [CI], -65.6 to -59.0) in EMR documentation of lifestyle counseling for patients with hypertension. Changes were smaller for indicators involving clinical actions that automatically update the EMR, such as laboratory testing, with a reduction of 10.7 percentage points (95% CI, -13.6 to -7.8) in control of cholesterol in patients with coronary heart disease and 12.1 percentage points (95% CI, -13.6 to -10.6) for thyroid-function testing in patients with hypothyroidism. There was little change in performance on the 6 quality measures for which incentives were maintained. CONCLUSIONS Removal of financial incentives was associated with an immediate decline in performance on quality measures. In part, the decline probably reflected changes in EMR documentation, but declines on measures involving laboratory testing suggest that incentive removal also changed the care delivered.
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Affiliation(s)
- Mark Minchin
- From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) - all in the United Kingdom
| | - Martin Roland
- From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) - all in the United Kingdom
| | - Judith Richardson
- From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) - all in the United Kingdom
| | - Shaun Rowark
- From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) - all in the United Kingdom
| | - Bruce Guthrie
- From the National Institute for Health and Care Excellence (NICE), Manchester (M.M., J.R., S.R.), the Department of Public Health and Primary Care, University of Cambridge, Cambridge (M.R.), and the Population Health and Genomics Division, University of Dundee, Dundee (B.G.) - all in the United Kingdom
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A reporting framework for describing and a typology for categorizing and analyzing the designs of health care pay for performance schemes. BMC Health Serv Res 2018; 18:686. [PMID: 30180838 PMCID: PMC6123918 DOI: 10.1186/s12913-018-3479-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Accepted: 08/17/2018] [Indexed: 01/02/2023] Open
Abstract
Background Pay for Performance (P4P) has increasingly being adopted in different countries as a provider payment mechanism to improve health system performance. Evaluations of pay for performance (P4P) schemes across several countries show significant variation in effectiveness, which may be explained by differences in design. There is however no reliable framework to structure the reporting of the design or a typology to help analyse and interpret results of P4P schemes. This paper reports the development of a reporting framework and a typology of P4P schemes. Methods P4P design features were identified from literature and then explored using relevant theories from behavioural and economic science. These design features were then combined with the help of multidimensional tables to produce a reporting framework and a typology which was tested using 74 P4P studies. The inter-rater reliability of the typology was assessed using Fleiss’ Kappa. Results A Healthcare Incentive Scheme Reporting Framework (HISReF) was developed consisting of nine design features. This was collapsed into a typology consisting of 4 items/design features. There was good inter-rater reliability on all the four items on the typology (kappa > 0.7). Conclusion The HISReF provides an important first step towards establishing a common language in which intervention designers can clearly specify the content of P4P designs. Our typology may be used to aid evidence synthesis and interpretation of results of P4P schemes. Electronic supplementary material The online version of this article (10.1186/s12913-018-3479-x) contains supplementary material, which is available to authorized users.
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Alonge O, Lin S, Igusa T, Peters DH. Improving health systems performance in low- and middle-income countries: a system dynamics model of the pay-for-performance initiative in Afghanistan. Health Policy Plan 2018; 32:1417-1426. [PMID: 29029075 PMCID: PMC5886199 DOI: 10.1093/heapol/czx122] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/15/2017] [Indexed: 11/14/2022] Open
Abstract
System dynamics methods were used to explore effective implementation pathways for improving health systems performance through pay-for-performance (P4P) schemes. A causal loop diagram was developed to delineate primary causal relationships for service delivery within primary health facilities. A quantitative stock-and-flow model was developed next. The stock-and-flow model was then used to simulate the impact of various P4P implementation scenarios on quality and volume of services. Data from the Afghanistan national facility survey in 2012 was used to calibrate the model. The models show that P4P bonuses could increase health workers' motivation leading to higher levels of quality and volume of services. Gaming could reduce or even reverse this desired effect, leading to levels of quality and volume of services that are below baseline levels. Implementation issues, such as delays in the disbursement of P4P bonuses and low levels of P4P bonuses, also reduce the desired effect of P4P on quality and volume, but they do not cause the outputs to fall below baseline levels. Optimal effect of P4P on quality and volume of services is obtained when P4P bonuses are distributed per the health workers' contributions to the services that triggered the payments. Other distribution algorithms such as equal allocation or allocations proportionate to salaries resulted in quality and volume levels that were substantially lower, sometimes below baseline. The system dynamics models served to inform, with quantitative results, the theory of change underlying P4P intervention. Specific implementation strategies, such as prompt disbursement of adequate levels of performance bonus distributed per health workers' contribution to service, increase the likelihood of P4P success. Poorly designed P4P schemes, such as those without an optimal algorithm for distributing performance bonuses and adequate safeguards for gaming, can have a negative overall impact on health service delivery systems.
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Affiliation(s)
- O Alonge
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E8622, Baltimore, MD 21205, USA
| | - S Lin
- Department of Civil Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - T Igusa
- Department of Civil Engineering, Johns Hopkins University, 3400 N Charles Street, Baltimore, MD 21218, USA
| | - D H Peters
- Department of International Health, Johns Hopkins Bloomberg School of Public Health, 615 N Wolfe Street, E8622, Baltimore, MD 21205, USA
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Ferreira MRJ, Mendes AN. Commodification in the reforms of the German, French and British health systems. CIENCIA & SAUDE COLETIVA 2018; 23:2159-2170. [PMID: 30020372 DOI: 10.1590/1413-81232018237.12972018] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2018] [Accepted: 06/01/2018] [Indexed: 11/22/2022] Open
Abstract
Since the 1980s, European health systems have undergone several reforms, with emphasis on the tendency of their commodification. The objective of this article is to demonstrate how market mechanisms were implemented in the functioning of these systems, german, british and french - from the 1980s. The "mercantile" reforms were justified on the premise that the insertion of market logic could both reduce the need for public spending and increase the efficiency of existing expenditure. The work presents different forms of commodification implemented in the reforms, with the distinction between processes of explicit commodification, in which there is an effective increase in private, and implicit presence, in which there is incorporation of principles from the private sector in the public system, both in financing and in the provision of health services. In addition to detailing the different ways in which this phenomenon is expressed, the article briefly presents the potential negative effects of this process for health systems, especially in terms of access and equity, stating that the initial assumptions surrounding commodification (cost reduction and efficiency improvement) appear to be false.
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Affiliation(s)
- Mariana Ribeira Jansen Ferreira
- Departamento de Economia, Pontifícia Universidade Católica de São Paulo. R. Monte Alegre 984, Perdizes. 05014-901 São Paulo SP Brasil.
| | - Aquilas Nogueira Mendes
- Departamento de Política, Gestão e Saúde, Faculdade de Saúde Pública, Universidade de São Paulo. São Paulo SP Brasil
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Garner BR, Lwin AK, Strickler GK, Hunter BD, Shepard DS. Pay-for-performance as a cost-effective implementation strategy: results from a cluster randomized trial. Implement Sci 2018; 13:92. [PMID: 29973280 PMCID: PMC6033288 DOI: 10.1186/s13012-018-0774-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2017] [Accepted: 05/31/2018] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Pay-for-performance (P4P) has been recommended as a promising strategy to improve implementation of high-quality care. This study examined the incremental cost-effectiveness of a P4P strategy found to be highly effective in improving the implementation and effectiveness of the Adolescent Community Reinforcement Approach (A-CRA), an evidence-based treatment (EBT) for adolescent substance use disorders (SUDs). METHODS Building on a $30 million national initiative to implement A-CRA in SUD treatment settings, urn randomization was used to assign 29 organizations and their 105 therapists and 1173 patients to one of two conditions (implementation-as-usual (IAU) control condition or IAU+P4P experimental condition). It was not possible to blind organizations, therapists, or all research staff to condition assignment. All treatment organizations and their therapists received a multifaceted implementation strategy. In addition to those IAU strategies, therapists in the IAU+P4P condition received US $50 for each month that they demonstrated competence in treatment delivery (A-CRA competence) and US $200 for each patient who received a specified number of treatment procedures and sessions found to be associated with significantly improved patient outcomes (target A-CRA). Incremental cost-effectiveness ratios (ICERs), which represent the difference between the two conditions in average cost per treatment organization divided by the corresponding average difference in effectiveness per organization, and quality-adjusted life years (QALYs) were the primary outcomes. RESULTS At trial completion, 15 organizations were randomized to the IAU condition and 14 organizations were randomized to the IAU+P4P condition. Data from all 29 organizations were analyzed. Cluster-level analyses suggested the P4P strategy led to significantly higher average total costs compared to the IAU control condition, yet this average increase of 5% resulted in a 116% increase in the average number of months therapists demonstrated competence in treatment delivery (ICER = $333), a 325% increase in the average number of patients who received the targeted dosage of treatment (ICER = $453), and a 325% increase in the number of days of abstinence per patient in treatment (ICER = $8.134). Further supporting P4P as a cost-effective implementation strategy, the cost per QALY was only $8681 (95% confidence interval $1191-$16,171). CONCLUSION This study provides experimental evidence supporting P4P as a cost-effective implementation strategy. TRIAL REGISTRATION NCT01016704 .
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Affiliation(s)
- Bryan R. Garner
- RTI International, P. O. Box 12194, Research Triangle Park, Raleigh, NC 27709-2194 USA
| | - Aung K. Lwin
- Schneider Institutes for Health Policy, The Heller School, MS035, Brandeis University, Waltham, MA USA
| | - Gail K. Strickler
- Schneider Institutes for Health Policy, The Heller School, MS035, Brandeis University, Waltham, MA USA
| | | | - Donald S. Shepard
- Schneider Institutes for Health Policy, The Heller School, MS035, Brandeis University, Waltham, MA USA
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Facciorusso A, Buccino RV, Muscatiello N. How to measure quality in endoscopic ultrasound. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:266. [PMID: 30094252 DOI: 10.21037/atm.2018.03.36] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Quality is a key focus for gastrointestinal endoscopy and main international gastroenterology societies instituted specific task forces focused on this issue. Endoscopic ultrasound (EUS) represents one of the most fascinating fields to explore in gastrointestinal endoscopy due to its relatively limited availability out of high-volume centers. This leads to a particular need to define widely accepted quality indicators (QIs) and the ways to measure them. The current manuscript reviews these indicators in light of their impact on common clinical practice.
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Affiliation(s)
- Antonio Facciorusso
- Department of Medical Sciences, Gastroenterology Unit, University of Foggia, Foggia, Italy
| | | | - Nicola Muscatiello
- Department of Medical Sciences, Gastroenterology Unit, University of Foggia, Foggia, Italy
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O’Leary KJ, Fant AL, Thurk J, Bilimoria KY, Didwania AK, Gleason KM, Groth M, Holl JL, Knoten CA, Martin GJ, O’Sullivan P, Schumacher M, Woods DM. Immediate and long-term effects of a team-based quality improvement training programme. BMJ Qual Saf 2018; 28:366-373. [DOI: 10.1136/bmjqs-2018-007894] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 04/30/2018] [Accepted: 05/03/2018] [Indexed: 11/03/2022]
Abstract
BackgroundAlthough many studies of quality improvement (QI) education programmes report improvement in learners’ knowledge and confidence, the impact on learners’ future engagement in QI activities is largely unknown and few studies report project measures beyond completion of the programme.MethodWe developed the Academy for Quality and Safety Improvement (AQSI) to prepare individuals, across multiple departments and professions, to lead QI. The 7-month programme consisted of class work and team-based project work. We assessed participants’ knowledge using a multiple choice test and an adapted Quality Improvement Knowledge Assessment Test (QIKAT) before and after the programme. We evaluated participants’ postprogramme QI activity and project status using surveys at 6 and 18 months.ResultsOver 5 years, 172 individuals and 32 teams participated. Participants had higher multiple choice test (71.9±12.7 vs 79.4±13.2; p<0.001) and adapted QIKAT scores (55.7±16.3 vs 61.8±14.7; p<0.001) after the programme. The majority of participants at 6 months indicated that they had applied knowledge and skills learnt to improve quality in their clinical area (129/148; 87.2%) and to implement QI interventions (92/148; 62.2%). At 18 months, nearly half (48/101; 47.5%) had led other QI projects and many (41/101; 40.6%) had provided QI mentorship to others. Overall, 14 (43.8%) teams had positive postintervention results at AQSI completion and 20 (62.5%) had positive results at some point (ie, completion, 6 months or 18 months after AQSI).ConclusionsA team-based QI training programme resulted in a high degree of participants’ involvement in QI activities beyond completion of the programme. A majority of team projects showed improvement in project measures, often occurring after completion of the programme.
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Agency-level financial incentives and electronic reminders to improve continuity of care after discharge from residential treatment and detoxification. Drug Alcohol Depend 2018; 183:192-200. [PMID: 29288914 PMCID: PMC5803317 DOI: 10.1016/j.drugalcdep.2017.11.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2017] [Revised: 09/08/2017] [Accepted: 11/03/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Despite the importance of continuity of care after detoxification and residential treatment, many clients do not receive further treatment services after discharged. This study examined whether offering financial incentives and providing client-specific electronic reminders to treatment agencies lead to improved continuity of care after detoxification or residential treatment. METHODS Residential (N = 33) and detoxification agencies (N = 12) receiving public funding in Washington State were randomized into receiving one, both, or none (control group) of the interventions. Agencies assigned to incentives arms could earn financial rewards based on their continuity of care rates relative to a benchmark or based on improvement. Agencies assigned to electronic reminders arms received weekly information on recently discharged clients who had not yet received follow-up treatment. Difference-in-difference regressions controlling for client and agency characteristics tested the effectiveness of these interventions on continuity of care. RESULTS During the intervention period, 24,347 clients received detoxification services and 20,685 received residential treatment. Overall, neither financial incentives nor electronic reminders had an effect on the likelihood of continuity of care. The interventions did have an effect among residential treatment agencies which had higher continuity of care rates at baseline. CONCLUSIONS Implementation of agency-level financial incentives and electronic reminders did not result in improvements in continuity of care, except among higher performing agencies. Alternative strategies at the facility and systems levels should be explored to identify ways to increase continuity of care rates in specialty settings, especially for low performing agencies.
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Expanding the breadth of Medicare: learning from Australia. HEALTH ECONOMICS POLICY AND LAW 2018; 13:344-368. [DOI: 10.1017/s1744133117000421] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractThe design of Australia’s Medicare programme was based on the Canadian scheme, adapted somewhat to take account of differences in the constitutional division of powers in the two countries and differences in history. The key elements are very similar: access to hospital services without charge being the core similarity, universal coverage for necessary medical services, albeit with a variable co-payment in Australia, the other. But there are significant differences between the two countries in health programmes – whether or not they are labelled as ‘Medicare’. This paper discusses four areas where Canada could potentially learn from Australia in a positive way. First, Australia has had a national Pharmaceutical Benefits Scheme for almost 70 years. Second, there have been hesitant extensions to Australia’s Medicare to address the increasing prevalence of people with chronic conditions – extensions which include some payments for allied health professionals, ‘care coordination’ payments, and exploration of ‘health care homes’. Third, Australia has a much more extensive system of support for older people to live in their homes or to move into supported residential care. Fourth, Australia has gone further in driving efficiency in the hospital sector than has Canada. Finally, the paper examines aspects of the Australian health care system that Canada should avoid, including the very high level of out-of-pocket costs, and the role of private acute inpatient provision.
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Garnick DW, Horgan CM, Acevedo A, Lee MT, Panas L, Ritter GA, Campbell K, Bean-Mortinson J. Influencing quality of outpatient SUD care: Implementation of alerts and incentives in Washington State. J Subst Abuse Treat 2017; 82:93-101. [PMID: 29021122 PMCID: PMC5653287 DOI: 10.1016/j.jsat.2017.09.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 09/08/2017] [Accepted: 09/12/2017] [Indexed: 12/18/2022]
Abstract
Financial incentives for quality improvement and feedback on specific clients are two approaches to improving the quality of treatment for individuals with substance use disorders. We examined the impacts of these interventions in Washington State by randomizing outpatient substance use treatment agencies into intervention and control groups. From October 2013 through December 2015, agencies could earn financial incentives for meeting performance goals incorporating both achievement relative to a benchmark and improvement from agencies' own baselines. Weekly feedback was e-mailed to agencies in the alert or alert plus incentives arms. Difference-in difference regressions controlling for client and agency characteristics showed that none of the interventions significantly affected client engagement after outpatient admissions, overall or for sub-groups based on race/ethnicity, age, rural residence, or agency baseline performance. Treatment agencies offered insights related to several themes: delivery system context (e.g., agency time and resources needed during transition to a managed behavioral healthcare system), implementation (e.g., data lag), agency issues (e.g., staff turnover), and client factors (e.g., motivation). Interventions took place during a time of Medicaid expansion and planning for statewide integration of mental health and substance use disorder treatment into a managed care model, which may have resulted in agencies not responding to the interventions. Moreover, incentives and alerts at the agency-level may not be effective when factors are at play beyond the agency's control.
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Affiliation(s)
- Deborah W Garnick
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, United States.
| | - Constance M Horgan
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, United States
| | - Andrea Acevedo
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, United States; Department of Community Health, Tufts University, United States
| | - Margaret T Lee
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, United States
| | - Lee Panas
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, United States
| | - Grant A Ritter
- Institute for Behavioral Health, The Heller School for Social Policy and Management, Brandeis University, United States
| | - Kevin Campbell
- The Division of Behavioral Health and Recovery, Washington State Behavioral Health Administration, United States
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Sieleunou I, Turcotte-Tremblay AM, Fotso JCT, Tamga DM, Yumo HA, Kouokam E, Ridde V. Setting performance-based financing in the health sector agenda: a case study in Cameroon. Global Health 2017; 13:52. [PMID: 28764720 PMCID: PMC5540528 DOI: 10.1186/s12992-017-0278-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Accepted: 07/16/2017] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND More than 30 countries in sub-Saharan Africa have introduced performance-based financing (PBF) in their healthcare systems. Yet, there has been little research on the process by which PBF was put on the national policy agenda in Africa. This study examines the policy process behind the introduction of PBF program in Cameroon. METHODS The research is an explanatory case study using the Kingdon multiple streams framework. We conducted a document review and 25 interviews with various types of actors involved in the policy process. We conducted thematic analysis using a hybrid deductive-inductive approach for data analysis. RESULTS By 2004, several reports and events had provided evidence on the state of the poor health outcomes and health financing in the country, thereby raising awareness of the situation. As a result, decision-makers identified the lack of a suitable health financing policy as an important issue that needed to be addressed. The change in the political discourse toward more accountability made room to test new mechanisms. A group of policy entrepreneurs from the World Bank, through numerous forms of influence (financial, ideational, network and knowledge-based) and building on several ongoing reforms, collaborated with senior government officials to place the PBF program on the agenda. The policy changes occurred as the result of two open policy windows (i.e. national and international), and in both instances, policy entrepreneurs were able to couple the policy streams to effect change. CONCLUSION The policy agenda of PBF in Cameroon underlined the importance of a perceived crisis in the policy reform process and the advantage of building a team to carry forward the policy process. It also highlighted the role of other sources of information alongside scientific evidence (eg.: workshop and study tour), as well as the role of previous policies and experiences, in shaping or influencing respectively the way issues are framed and reformers' actions and choices.
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Affiliation(s)
- Isidore Sieleunou
- University of Montreal, 7101, avenue du Parc, Montréal, Québec H3N 1X9 Canada
- Research for Development International, 30883 Yaoundé, Cameroon
| | | | | | | | | | - Estelle Kouokam
- Université Catholique d’Afrique Centrale, 11628 Nkolbisson, Yaoundé, Cameroon
| | - Valery Ridde
- University of Montreal, 7101, avenue du Parc, Montréal, Québec H3N 1X9 Canada
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Zhang W, Luo H, Ma Y, Guo Y, Fang Q, Yang Z, Zhang X, Zhang X, Jia M, Chen XS. Monetary incentives for provision of syphilis screening, Yunnan, China. Bull World Health Organ 2017; 95:657-662. [PMID: 28867847 PMCID: PMC5578386 DOI: 10.2471/blt.17.191635] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 06/08/2017] [Accepted: 06/09/2017] [Indexed: 12/01/2022] Open
Abstract
Problem Early detection of syphilis-infected people followed by effective treatment is essential for syphilis prevention and control. Approach Starting in 2010 the local health authority in Yunnan province, China, developed a network of 670 service sites for syphilis testing, diagnosis and treatment or for testing-only with referral for further diagnosis and treatment. Point-of-care tests for syphilis and syphilis interventions were integrated into the existing human immunodeficiency virus (HIV) prevention and control programme. To improve the syphilis services, a pay-for-performance scheme was introduced in which providers were paid for testing and treating patients. Local setting Yunnan province is the region hardest hit by HIV infection and disproportionately burdened with syphilis cases in China. Relevant changes The proportion of attendees at voluntary counselling and testing clinics who were tested for syphilis increased from 46.2% (32 877/71 162) in 2010 to 98.2% (68 012/69 259) in 2015. Syphilis-infected cases treated with the recommended therapy increased from 26.6% (264/993) in 2010 to 82.5% (453/549) in 2015 at designated testing, diagnosis and treatment sites. Lessons learnt The strategy greatly increased the uptake of syphilis testing and treatment among people at risk. Introduction of point-of-care tests for syphilis increased coverage of the testing services. Introduction of a pay-for-performance scheme seemed to motivate health-care providers to undertake syphilis intervention services.
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Affiliation(s)
- Wanyue Zhang
- Yunnan Provincial Centre for Disease Control and Prevention, 158 Dongsi Road, Kunmin, China
| | - Hongbin Luo
- Yunnan Provincial Centre for Disease Control and Prevention, 158 Dongsi Road, Kunmin, China
| | - Yanling Ma
- Yunnan Provincial Centre for Disease Control and Prevention, 158 Dongsi Road, Kunmin, China
| | - Yan Guo
- Yunnan Provincial Centre for Disease Control and Prevention, 158 Dongsi Road, Kunmin, China
| | - Qingyan Fang
- Yunnan Provincial Centre for Disease Control and Prevention, 158 Dongsi Road, Kunmin, China
| | - Zhifang Yang
- Yunnan Provincial Centre for Disease Control and Prevention, 158 Dongsi Road, Kunmin, China
| | - Xiujie Zhang
- Yunnan Provincial Centre for Disease Control and Prevention, 158 Dongsi Road, Kunmin, China
| | - Xiaobin Zhang
- Yunnan Provincial Centre for Disease Control and Prevention, 158 Dongsi Road, Kunmin, China
| | - Manhong Jia
- Yunnan Provincial Centre for Disease Control and Prevention, 158 Dongsi Road, Kunmin, China
| | - Xiang-Sheng Chen
- National Center for Sexually Transmitted Disease Control, China Centre for Diseases Control and Prevention, Nanjing, China
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Herbst T, Emmert M. Characterization and effectiveness of pay-for-performance in ophthalmology: a systematic review. BMC Health Serv Res 2017; 17:385. [PMID: 28583141 PMCID: PMC5460462 DOI: 10.1186/s12913-017-2333-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Accepted: 05/25/2017] [Indexed: 11/11/2022] Open
Abstract
Background To identify, characterize and compare existing pay-for-performance approaches and their impact on the quality of care and efficiency in ophthalmology. Methods A systematic evidence-based review was conducted. English, French and German written literature published between 2000 and 2015 were searched in the following databases: Medline (via PubMed), NCBI web site, Scopus, Web of Knowledge, Econlit and the Cochrane Library. Empirical as well as descriptive articles were included. Controlled clinical trials, meta-analyses, randomized controlled studies as well as observational studies were included as empirical articles. Systematic characterization of identified pay-for-performance approaches (P4P approaches) was conducted according to the “Model for Implementing and Monitoring Incentives for Quality” (MIMIQ). Methodological quality of empirical articles was assessed according to the Critical Appraisal Skills Programme (CASP) checklists. Results Overall, 13 relevant articles were included. Eleven articles were descriptive and two articles included empirical analyses. Based on these articles, four different pay-for-performance approaches implemented in the United States were identified. With regard to quality and incentive elements, systematic comparison showed numerous differences between P4P approaches. Empirical studies showed isolated cost or quality effects, while a simultaneous examination of these effects was missing. Conclusion Research results show that experiences with pay-for-performance approaches in ophthalmology are limited. Identified approaches differ with regard to quality and incentive elements restricting comparability. Two empirical studies are insufficient to draw strong conclusions about the effectiveness and efficiency of these approaches. Electronic supplementary material The online version of this article (doi:10.1186/s12913-017-2333-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tim Herbst
- nordBLICK Augenklinik Bellevue, Lindenallee 21-23, 24105, Kiel, Germany.
| | - Martin Emmert
- Friedrich-Alexander-University Erlangen-Nuremberg, School of Business and Economics, Institute of Management (IFM), Lange Gasse 20, 90403, Nuremberg, Germany.
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Sicsic J, Franc C. Impact assessment of a pay-for-performance program on breast cancer screening in France using micro data. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2017; 18:609-621. [PMID: 27329654 DOI: 10.1007/s10198-016-0813-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2015] [Accepted: 06/14/2016] [Indexed: 06/06/2023]
Abstract
BACKGROUND A voluntary-based pay-for-performance (P4P) program (the CAPI) aimed at general practitioners (GPs) was implemented in France in 2009. The program targeted prevention practices, including breast cancer screening, by offering a maximal amount of €245 for achieving a target screening rate among eligible women enrolled with the GP. OBJECTIVE Our objective was to evaluate the impact of the French P4P program (CAPI) on the early detection of breast cancer among women between 50 and 74 years old. METHODS Based on an administrative database of 50,752 women aged 50-74 years followed between 2007 and 2011, we estimated a difference-in-difference model of breast cancer screening uptake as a function of visit to a CAPI signatory referral GP, while controlling for both supply-side and demand-side determinants (e.g., sociodemographics, health and healthcare use). RESULTS Breast cancer screening rates have not changed significantly since the P4P program implementation. Overall, visiting a CAPI signatory referral GP at least once in the pre-CAPI period increased the probability of undergoing breast cancer screening by 1.38 % [95 % CI (0.41-2.35 %)], but the effect was not significantly different following the implementation of the contract. CONCLUSION The French P4P program had a nonsignificant impact on breast cancer screening uptake. This result may reflect the fact that the low-powered incentives implemented in France through the CAPI might not provide sufficient leverage to generate better practices, thus inviting regulators to seek additional tools beyond P4P in the field of prevention and screening.
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Affiliation(s)
- Jonathan Sicsic
- CESP, Univ. Paris-Sud, UVSQ, INSERM, Université Paris-Saclay, Hôpital Paul Brousse, 16 avenue Paul Vaillant-Couturier, 94807, Villejuif Cedex, France.
| | - Carine Franc
- CESP, Univ. Paris-Sud, UVSQ, INSERM, Université Paris-Saclay, Hôpital Paul Brousse, 16 avenue Paul Vaillant-Couturier, 94807, Villejuif Cedex, France
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Abstract
BACKGROUND Taiwan's National Health Insurance program implemented a pay-for-performance (P4P) program based on process measures in 2001. In late 2006, the P4P was revised to also include achievement of outcome measures. OBJECTIVES This study examined whether a change in P4P incentive design structure affected diabetes outcomes. RESEARCH DESIGN AND METHOD We used a longitudinal cohort study design using 2 population-based databases. Newly enrolled P4P patients with diabetes in 2002-2003 (phase 1) and 2007-2008 (phase 2) made up the study cohorts. Propensity score matching was used to match comparable cohorts in each phase. In total, 46,286 matched cohorts in phase 1 and 2 were analyzed. Process measures were defined as the provision of tests of glycosylated hemoglobin A1c (HbA1c), low-density lipoprotein cholesterol, and blood pressure, and outcome measures as changes in those values between baseline and last follow-up within 3 years. Patient-level generalized linear regression models were used and patient characteristics, physician characteristics, and health care facility characteristics were adjusted for. RESULTS Our results indicated that the process measures of HbA1c and low-density lipoprotein cholesterol tests did not differ significantly between the 2 phases. In addition, better improvements were noted in outcome measures for the phase 2 patients (ie, HbA1c level and lipid profiles), whereas nonincentivized intermediate measures (eg, blood pressure) showed no negative unintended consequences. CONCLUSIONS Quality of care tended to be better when both process and targeted outcome measures were combined as quality metrics in the P4P program in Taiwan.
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The influence of welfare systems on pay-for-performance programs for general practitioners: A critical review. Soc Sci Med 2017; 178:157-166. [PMID: 28226301 DOI: 10.1016/j.socscimed.2017.02.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 02/10/2017] [Accepted: 02/12/2017] [Indexed: 12/11/2022]
Abstract
While pay-for-performance (P4P) programs are increasingly common tools used to foster quality and efficiency in primary care, the evidence concerning their effectiveness is at best mixed. In this article, we explore the influence of welfare systems on four P4P-related dimensions: the level of healthcare funders' commitment to P4Ps (by funding and length of program operation), program design (specifically target-based vs. participation-based program), physicians' acceptance of the program and program effects. Using Esping-Andersen's typology, we examine P4P for general practitioners (GPs) in thirteen European and North American countries and find that welfare systems contribute to explain variations in P4P experiences. Overall, liberal systems exhibited the most enthusiastic adoption of P4P, with significant physician acceptance, generous incentives and positive but modest program effects. Social democratic countries showed minimal interest in P4P for GPs, with the exception of Sweden. Although corporatist systems adopted performance pay, these countries experienced mixed results, with strong physician opposition. In response to this opposition, health care funders tended to favour participation-based over target-based P4P. We demonstrate how the interaction of decommodification and social stratification in each welfare regime influences these countries' experiences with P4P for GPs, directly for funders' commitment, program design and physicians' acceptance, and indirectly for program effects, hence providing a framework for analyzing P4P in other contexts or care settings.
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Roseboom KJ, van Dongen JM, Tompa E, van Tulder MW, Bosmans JE. Economic evaluations of health technologies in Dutch healthcare decision-making: a qualitative study of the current and potential use, barriers, and facilitators. BMC Health Serv Res 2017; 17:89. [PMID: 28126005 PMCID: PMC5270365 DOI: 10.1186/s12913-017-1986-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2015] [Accepted: 01/04/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The use of economic evaluations in healthcare decision-making can potentially help decision-makers in allocating scarce resources as efficiently as possible. Over a decade ago, the use of such studies was found to be limited in Dutch healthcare decision-making, but their current use is unknown. Therefore, this study aimed to provide insight into the current and potential use of economic evaluations in Dutch healthcare decision-making and to identify barriers and facilitators to the use of such studies. METHODS Interviews containing semi-structured and structured questions were conducted among Dutch healthcare decision-makers. Participants were purposefully selected and special efforts were made to include decision-makers working at the macro- (national), meso- (local/regional), and micro-level (patient setting). During the interviews, a topic list was used that was based on the research questions and a literature search, and was developed in consultation with the Dutch National Healthcare Institute. Responses to the semi-structured questions were analyzed using a constant comparative approach. As for the structured questions, participants' definitions of various economic evaluation concepts were scored as either being "correct" or "incorrect" by two researchers, and summary statistics were prepared. RESULTS Sixteen healthcare decision-makers were interviewed and two health economists. Decision-makers' knowledge of economic evaluations was only modest, and their current use appeared to be limited. Nonetheless, decision-makers recognized the importance of economic evaluations and saw several opportunities for extending their use at the macro- and meso-level, but not at the micro-level. The disparity between the limited use and recognition of the importance of economic evaluations is likely due to the many barriers decision-makers experience preventing their use (e.g. lack of resources, lack of formal willingness-to-pay threshold). Possible facilitators for extending the use of economic evaluations include, amongst others, educating decision-makers and the general population about economic evaluations and presenting economic evaluation results in a clearer and more understandable way. CONCLUSIONS This study demonstrated that the current use and impact of economic evaluations in Dutch healthcare decision-making is limited at best. Therefore, strategies are needed to overcome the barriers that currently prevent economic evaluations from being used extensively.
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Affiliation(s)
- Kitty J Roseboom
- Department of Health Sciences and the EMGO+ Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Johanna M van Dongen
- Department of Health Sciences and the EMGO+ Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands.
| | - Emile Tompa
- Institute for Work & Health, 481 University Avenue Suite 800, Toronto, ON, M5G 2E9, Canada.,Department of Economics, McMaster University, Kenneth Taylor Hall Room 426, 1280 Main Street West, Hamilton, ON, L8S 4 M4, Canada.,Dalla Lana School of Public Health, University of Toronto, 155 College Street Health Science Building, 6th floor, Toronto, ON, M5T 3 M7, Canada
| | - Maurits W van Tulder
- Department of Health Sciences and the EMGO+ Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
| | - Judith E Bosmans
- Department of Health Sciences and the EMGO+ Institute for Health and Care Research, Faculty of Earth and Life Sciences, VU University Amsterdam, De Boelelaan 1085, 1081 HV, Amsterdam, The Netherlands
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Ammi M, Peyron C. Heterogeneity in general practitioners' preferences for quality improvement programs: a choice experiment and policy simulation in France. HEALTH ECONOMICS REVIEW 2016; 6:44. [PMID: 27637834 PMCID: PMC5025412 DOI: 10.1186/s13561-016-0121-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 09/08/2016] [Indexed: 05/27/2023]
Abstract
Despite increasing popularity, quality improvement programs (QIP) have had modest and variable impacts on enhancing the quality of physician practice. We investigate the heterogeneity of physicians' preferences as a potential explanation of these mixed results in France, where the national voluntary QIP - the CAPI - has been cancelled due to its unpopularity. We rely on a discrete choice experiment to elicit heterogeneity in physicians' preferences for the financial and non-financial components of QIP. Using mixed and latent class logit models, results show that the two models should be used in concert to shed light on different aspects of the heterogeneity in preferences. In particular, the mixed logit demonstrates that heterogeneity in preferences is concentrated on the pay-for-performance component of the QIP, while the latent class model shows that physicians can be grouped in four homogeneous groups with specific preference patterns. Using policy simulation, we compare the French CAPI with other possible QIPs, and show that the majority of the physician subgroups modelled dislike the CAPI, while favouring a QIP using only non-financial interventions. We underline the importance of modelling preference heterogeneity in designing and implementing QIPs.
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Affiliation(s)
- Mehdi Ammi
- School of Public Policy and Administration, Carleton University, River Building, 1125 Colonel By Drive, Ottawa, ON, K1S 5B6, Canada.
| | - Christine Peyron
- Laboratoire d'Économie de Dijon, Université de Bourgogne, CNRS UMR 6307, Inserm U 1200, Dijon, France
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Allen T, Whittaker W, Sutton M. Does the proportion of pay linked to performance affect the job satisfaction of general practitioners? Soc Sci Med 2016; 173:9-17. [PMID: 27914316 DOI: 10.1016/j.socscimed.2016.11.028] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 11/09/2016] [Accepted: 11/21/2016] [Indexed: 11/15/2022]
Abstract
There is concern that pay-for-performance (P4P) can negatively affect general practitioners (GPs) by reducing their autonomy, increasing their wage dispersion or eroding their intrinsic motivation. This is especially a concern for the Quality and Outcomes Framework (QOF), a highly powered P4P scheme for UK GPs. The QOF affected all GPs but the exposure of their income to P4P varied. GPs did not know their level of exposure before the QOF was introduced and could not choose or manage it. We examine whether changes in GPs' job satisfaction before and after the introduction of the QOF in 2004 were correlated with the proportion of their income that became exposed to P4P. We use data on 1920 GPs observed at three time points spanning the introduction of the QOF; 2004, 2005 and 2008. We estimate the effect of exposure to P4P using a continuous difference-in-differences model. We find no significant effects of P4P exposure on overall job satisfaction or 12 additional measures of working lives in either the short or longer term. The level of exposure to P4P does not harm job satisfaction or other aspects of working lives. Policies influencing the exposure of income to P4P are unlikely to alter GP job satisfaction subject to final income remaining constant.
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Affiliation(s)
- Thomas Allen
- Manchester Centre for Health Economics, University of Manchester, UK.
| | - William Whittaker
- Manchester Centre for Health Economics, University of Manchester, UK
| | - Matt Sutton
- Manchester Centre for Health Economics, University of Manchester, UK
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Ashcroft R, Menear M, Silveira J, Dahrouge S, McKenzie K. Incentives and disincentives for treating of depression and anxiety in Ontario Family Health Teams: protocol for a grounded theory study. BMJ Open 2016; 6:e014623. [PMID: 28186951 PMCID: PMC5128770 DOI: 10.1136/bmjopen-2016-014623] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION There is strong consensus that prevention and management of common mental disorders (CMDs) should occur in primary care and evidence suggests that treatment of CMDs in these settings can be effective. New interprofessional team-based models of primary care have emerged that are intended to address problems of quality and access to mental health services, yet many people continue to struggle to access care for CMDs in these settings. Insufficient attention directed towards the incentives and disincentives that influence care for CMDs in primary care, and especially in interprofessional team-based settings, may have resulted in missed opportunities to improve care quality and control healthcare costs. Our research is driven by the hypothesis that a stronger understanding of the full range of incentives and disincentives at play and their relationships with performance and other contextual factors will help stakeholders identify the critical levers of change needed to enhance prevention and management of CMDs in interprofessional primary care contexts. Participant recruitment began in May 2016. METHODS AND ANALYSIS An explanatory qualitative design, based on a constructivist grounded theory methodology, will be used. Our study will be conducted in the Canadian province of Ontario, a province that features a widely implemented interprofessional team-based model of primary care. Semistructured interviews will be conducted with a diverse range of healthcare professionals and stakeholders that can help us understand how various incentives and disincentives influence the provision of evidence-based collaborative care for CMDs. A final sample size of 100 is anticipated. The protocol was peer reviewed by experts who were nominated by the funding organisation. ETHICS AND DISSEMINATION The model we generate will shed light on the incentives and disincentives that are and should be in place to support high-quality CMD care and help stimulate more targeted, coordinated stakeholder responses to improving primary mental healthcare quality.
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Affiliation(s)
- Rachelle Ashcroft
- Factor-Inwentash Faculty of Social Work, University of Toronto, Toronto, Ontario, Canada
| | - Matthew Menear
- CHU de Quebec Research Centre, Quebec City, Quebec, Canada
- Department of Family Medicine and Emergency Medicine, Laval University, Quebec City, Quebec, Canada
| | - Jose Silveira
- Mental Health and Addiction Program, St. Joseph's Health Centre, Toronto, Ontario, Canada
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Simone Dahrouge
- C.T. Lamont Primary Health Care Research Centre, Bruyere Research Institute, Ottawa, Ontario, Canada
| | - Kwame McKenzie
- Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
- Wellesley Institute, Toronto, Ontario, Canada
- Centre for Addiction and Mental Health, Toronto, Ontario, Canada
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Grytten J. Payment systems and incentives in dentistry. Community Dent Oral Epidemiol 2016; 45:1-11. [DOI: 10.1111/cdoe.12267] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 10/06/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Jostein Grytten
- Department of Community Dentistry; University of Oslo; Oslo Norway
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