Physician payment methods: a focus on quality and cost control

Primary care services and emergency department visits in blended fee-for-service and blended capitation models: evidence from Ontario, Canada

INTRODUCTION

It is well-known that the way physicians are remunerated can affect delivery of health care services to the population. Fee-for-service (FFS) generally leads to oversupply of services, while capitation leads to undersupply of services. However, little evidence exists on the link between remuneration and emergency department (ED) visits. We fill this gap using two popular blended models introduced in Ontario, Canada: the Family Health Group (FHG), an enhanced/blended FFS model, and Family Health Organization (FHO), a blended capitation model. We compare primary care services and rates of emergency department ED visits between these two models. We also evaluate whether these outcomes vary by regular- and after-hours, and patient morbidity status.

METHODS

Physicians practicing in an FHG or FHO between April 2012 and March 2017 and their enrolled adult patients were included for analyses. The covariate-balancing propensity score weighting method was used to remove the influence of observable confounding and negative-binomial and linear regression models were used to evaluate the rates of primary care services, ED visits, and the dollar value of primary care services delivered between FHGs and FHOs. Visits were stratified as regular- and after-hours. Patients were stratified into three morbidity groups: non-morbid, single-morbid, and multimorbid (two or more chronic conditions).

RESULTS

6184 physicians and their patients were available for analysis. Compared to FHG physicians, FHO physicians delivered 14% (95% CI 13%, 15%) fewer primary care services per patient per year, with 27% fewer services during after-hours (95% CI 25%, 29%). Patients enrolled to FHO physicians made 27% more less-urgent (95% CI 23%, 31%) and 10% more urgent (95% CI 7%, 13%) ED visits per patient per year, with no difference in very-urgent ED visits. Differences in the pattern of ED visits were similar during regular- and after-hours. Although FHO physicians provided fewer services, multimorbid patients in FHOs made fewer very-urgent and urgent ED visits, with no difference in less-urgent ED visits.

CONCLUSION

Primary care physicians practicing in Ontario's blended capitation model provide fewer primary care services compared to those practicing in a blended FFS model. Although the overall rate of ED visits was higher among patients enrolled to FHO physicians, multimorbid patients of FHO physicians make fewer urgent and very-urgent ED visits.

Pre-doctoral dental faculty perceptions toward value-based care: An exploratory study

OBJECTIVES

To explore pre-doctoral faculty perceptions toward implementation of value-based care (VBC) in didactic and clinical teaching.

METHODS

This project was a collaborative effort between CareQuest and the University of North Carolina at Chapel Hill, Adams School of Dentistry introducing VBC to pre-doctoral dental faculty as part of a new curriculum. Following a faculty development session on VBC in June 2021, faculty and subject matter experts were invited to participate in qualitative interviews. Subject matter experts were interviewed to establish a baseline for VBC knowledge and understanding. Interviews were recorded and transcribed verbatim. Analysis was conducted by two analysts using ATLAS.ti and a thematic analysis approach.

RESULTS

Six faculty and two subject matter experts participated in interviews. Although dental faculty demonstrated some understanding of VBC, they recognized that more training is required to build in-depth knowledge and implementation strategies for teaching dental students. Faculty discussed value-based concepts such as prevention-focused teaching, person-centered care, and disease management over invasive restoration of teeth, and how VBC is bringing about a paradigm shift in dentistry that needs to be reflected in dental education. They acknowledged a disconnect between VBC in didactic teaching versus clinical instruction. Those interviewed believed it would take time to shift faculty mindset and readiness to teach VBC, and continued efforts are needed at the leadership and faculty level for acceptance and implementation.

CONCLUSIONS

Although dental faculty recognize that VBC can bring a shift in dental practice, more training and guidance to implement it in didactic and clinical teaching is needed.

Physician influence on medication adherence, evidence from a population-based cohort

BACKGROUND

The overall impact of physician prescribers on population-level adherence rates are unknown. We aimed to quantify the influence of general practitioner (GP) physician prescribers on the outcome of optimal statin medication adherence.

METHODS

We conducted a retrospective cohort study using health administrative databases from Saskatchewan, Canada. Participants included physician prescribers and their patients beginning a new statin medication between January 1, 2012 and December 31, 2017. We grouped prescribers based on the prevalence of optimal adherence (i.e., proportion of days covered ≥ 80%) within their patient group. Also, we constructed multivariable logistic regression analyses on optimal statin adherence using two-level non-linear mixed-effects models containing patient and prescriber-level characteristics. An intraclass correlation coefficient was used to estimate the physician effect.

RESULTS

We identified 1,562 GPs prescribing to 51,874 new statin users. The median percentage of optimal statin adherence across GPs was 52.4% (inter-quartile range: 35.7% to 65.5%). GP prescribers with the highest patient adherence (versus the lowest) had patients who were older (median age 61.0 vs 55.0, p<0.0001) and sicker (prior hospitalization 39.4% vs 16.4%, p<0.001). After accounting for patient-level factors, only 6.4% of the observed variance in optimal adherence between patients could be attributed to GP prescribers (p<0.001). The majority of GP prescriber influence (5.2% out of 6.4%) was attributed to the variance unexplained by patient and prescriber variables.

INTERPRETATION

The overall impact of GP prescribers on statin adherence appears to be very limited. Even "high-performing" physicians face significant levels of sub-optimal adherence among their patients.

Management of human resources for health: implications for health systems efficiency in Kenya

Background

Human resources for health consume a substantial share of healthcare resources and determine the efficiency and overall performance of health systems. Under Kenya’s devolved governance, human resources for health are managed by county governments. The aim of this study was to examine how the management of human resources for health influences the efficiency of county health systems in Kenya.

Methods

We conducted a case study using a mixed methods approach in two purposively selected counties in Kenya. We collected data through in-depth interviews (n = 46) with national and county level HRH stakeholders, and document and secondary data reviews. We analyzed qualitative data using a thematic approach, and quantitative data using descriptive analysis.

Results

Human resources for health in the selected counties was inadequately financed and there were an insufficient number of health workers, which compromised the input mix of the health system. The scarcity of medical specialists led to inappropriate task shifting where nonspecialized staff took on the roles of specialists with potential undesired impacts on quality of care and health outcomes. The maldistribution of staff in favor of higher-level facilities led to unnecessary referrals to higher level (referral) hospitals and compromised quality of primary healthcare. Delayed salaries, non-harmonized contractual terms and incentives reduced the motivation of health workers. All of these effects are likely to have negative effects on health system efficiency.

Conclusions

Human resources for health management in counties in Kenya could be reformed with likely positive implications for county health system efficiency by increasing the level of funding, resolving funding flow challenges to address the delay of salaries, addressing skill mix challenges, prioritizing the allocation of health workers to lower-level facilities, harmonizing the contractual terms and incentives of health workers, and strengthening monitoring and supervision.

Overview of Cardiothoracic Surgeon Compensation: Practice Setting, Productivity, and Payment Structures

The Centers for Medicare and Medicaid Services recently proposed a substantial cut to reimbursement for surgical services, punctuating a steady decline in reimbursement for clinical services provided by cardiothoracic surgeons during the last several decades. Meanwhile, the costs of practicing cardiothoracic surgery continue to increase. In an effort to defect against diminishing control over patient care and further negative changes affecting reimbursement, cardiothoracic surgeons must be able to convincingly demonstrate their value to patients and the health care system. However, the overall contribution of a cardiothoracic surgeon can be difficult to measure objectively and varies widely according to a host of factors, including practice setting, experience, subspecialization, and the local market. To address these challenges, The Society of Thoracic Surgeons Workforce on Practice Management has commissioned a Writing Task Force to raise awareness, to concentrate knowledge, and to organize information related to compensation as a comprehensive resource for cardiothoracic surgeons. The purpose of this initial report is to provide an overview of the major factors having an impact on compensation for cardiothoracic surgeons.

Increasing likelihood of prescribing recommended lipid management: Primary care providers' participation in cardiology continuing medical education

OBJECTIVE

To explore whether participation in a series of cardiology continuing medical education (CME) activities affects primary care providers' (PCPs') lipid management for their patients.

DESIGN

This retrospective cohort study used a database of participation in cardiology CME activities (2011 to 2017) linked to electronic medical records. Statistical analyses were completed using logistic regression with generalized estimating equations.

SETTING

Manitoba.

PARTICIPANTS

Patients receiving care from 225 PCPs participating in the Manitoba Primary Care Research Network.

MAIN OUTCOME MEASURES

Recommended lipid management was defined as prescription of statins (yes or no) among patients diagnosed with cardiovascular disease (CVD), patients diagnosed with diabetes mellitus (DM; 40 years or older), and patients diagnosed with chronic kidney disease (CKD; 50 years and older) in 2017. Treatment was identified using the ATC (Anatomical Therapeutic Chemical) system (ATC code C10AA or C10B).

RESULTS

After adjusting for relevant confounders, the odds of prescribing statins to patients with CVD, DM, or CKD among PCPs who did not participate in the cardiology CME activities were 50%, 55%, and 67% lower, respectively, than among PCPs who participated in 2 or more activities. The odds of prescribing statins to patients with CVD and DM among PCPs who participated in only 1 cardiology CME activity were also 67% and 63% lower, respectively, than among PCPs who participated in 2 or more activities.

CONCLUSION

Results suggested that PCPs who participated in 2 or more cardiology CME activities were more likely to prescribe recommended lipid management (statins) for adults with CVD, DM, or CKD.

How can Saudi Arabia reform its public hospital payment models? A narrative review

BACKGROUND

The cost of Saudi healthcare continues to rise at an alarming rate, putting the sustainability of the public healthcare system into question. Data have shown that hospital and healthcare providers' services represent the bulk of this rising cost, which makes the calls to reform the Saudi healthcare system more focused on payment models than at any time before.

OBJECTIVE

The aim of this paper is to review various identified payment models that can be used to contain costs and improve the quality of the care provided.

METHOD

A literature review of articles addressing the issues of cost containment and improving the quality of healthcare by reforming the current Saudi healthcare payment policy were identified through the Ovid®, Medline, and Google® Scholar search engines.

RESULTS AND CONCLUSIONS

Many research articles and literature reviews have identified and discussed different models of healthcare payments. Some articles have focused on one payment model, while others have discussed different payment models that have been identified. There is an urgent need to reform the current system of healthcare payments to improve the quality of healthcare and maintain funding for universal healthcare coverage in the future. Future healthcare payment reforms should consider restructuring the current healthcare system, which is largely fragmented by providing incentives to different governmental healthcare sectors, in order to transform it into a more organized and coordinated system. Thus far, there is not a single payment model that can, by itself, reduce healthcare costs and improve healthcare quality. Future healthcare reforms should use a mixture of different payment models to pay hospitals and physicians.

Effects of capitation payment on utilization and claims expenditure under National Health Insurance Scheme: a cross-sectional study of three regions in Ghana

INTRODUCTION

Ghana introduced capitation payment under National Health Insurance Scheme (NHIS), beginning with pilot in the Ashanti region, in 2012 with a key objective of controlling utilization and related cost. This study sought to analyse utilization and claims expenditure data before and after introduction of capitation payment policy to understand whether the intended objective was achieved.

METHODS

The study was cross-sectional, using a non-equivalent pre-test and post-test control group design. We did trend analysis, comparing utilization and claims expenditure data from three administrative regions of Ghana, one being an intervention region and two being control regions, over a 5-year period, 2010-2014. We performed multivariate analysis to determine differences in utilization and claims expenditure between the intervention and control regions, and a difference-in-differences analysis to determine the effect of capitation payment on utilization and claims expenditure in the intervention region.

RESULTS

Findings indicate that growth in outpatient utilization and claims expenditure increased in the pre capitation period in all three regions but slowed in post capitation period in the intervention region. The linear regression analysis showed that there were significant differences in outpatient utilization (p = 0.0029) and claims expenditure (p = 0.0003) between the intervention and the control regions before implementation of the capitation payment. However, only claims expenditure showed significant difference (p = 0.0361) between the intervention and control regions after the introduction of capitation payment. A difference-in-differences analysis, however, showed that capitation payment had a significant negative effect on utilization only, in the Ashanti region (p < 0.007). Factors including availability of district hospitals and clinics were significant predictors of outpatient health care utilization.

CONCLUSION

We conclude that outpatient utilization and related claims expenditure increased in both pre and post capitation periods, but the increase in post capitation period was at slower rate, suggesting that implementation of capitation payment yielded some positive results. Health policy makers in Ghana may, therefore, want to consider capitation a key provider payment method for primary outpatient care in order to control cost in health care delivery.

A narrative synthesis of illustrative evidence on effects of capitation payment for primary care: lessons for Ghana and other low/middle-income countries

OBJECTIVE

To analyse and synthesize available international experiences and information on the motivation for, and effects of using capitation as provider payment method in country health systems and lessons and implications for low/middle-income countries.

METHODS

We did narrative review and synthesis of the literature on the effects of capitation payment on primary care.

RESULTS

Eleven articles were reviewed. Capitation payment encourages efficiency: drives down cost, serves as critical source of income for providers, promotes adherence to guidelines and policies, encourages providers to work better and give health education to patients. It, however, induces reduction in the quantity and quality of care provided and encourages skimming on inputs, underserving of patients in bad state of health, "dumping" of high risk patients and negatively affect patient-provider relationship.

CONCLUSION

The illustrative evidence adduced from the review demonstrates that capitation payment in primary care can create positive incentives but could also elicit un-intended effects. However, due to differences in country context, policy makers in Ghana and other low/middle-income countries may only be guided by the illustrative evidence in their design of a context-specific capitation payment for primary care.

FUNDING

Netherlands Fellowship Programme (NFP), Fellowship number: NFP-PhD.12/352.

Health System Reform Plan and Performance of Hospitals: an Iranian Case Study

Background:

Health system reform is essential to make desired Changes. In Iran, first phase of Health Reform Plan (HRP) was implemented in hospitals affiliated with Ministry of Health and Medical Education (MHME) in 2014.

Aim:

The present study was carried out to evaluate the performance of hospitals affiliated with Urmia University of Medical Sciences at the time of the implementation of HRP.

Methods:

This cross-sectional study carried out in two stages, before (2012- 2013) and during (2014- 2015) implementation of the HRP in district and teaching hospitals. Data collection and evaluation of performance of hospitals was performed using indices issued by MHME using graphical and statistical analysis.

Results:

Average bed occupancy rate and bed turnover rate increased and the average length of stay decreased in the majority of hospitals during the study period. The highest and lowest bed occupancy rate was observed in district hospitals. All hospitals were shifted toward the third zone in Pabon Lasso (PL) diagram.

Conclusion:

This study confirmed that the implementation of the defined package of HRP in hospitals affiliated with UUMS resulted in increased admissions and hospitalization and improved performance.