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Anders A. Reconsidering performance management to support innovative changes in health care services. J Health Organ Manag 2024; 38:125-142. [PMID: 38546186 PMCID: PMC10988776 DOI: 10.1108/jhom-12-2022-0379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 12/15/2023] [Accepted: 02/18/2024] [Indexed: 04/05/2024]
Abstract
PURPOSE A large number of studies indicate that coercive forms of organizational control and performance management in health care services often backfire and initiate dysfunctional consequences. The purpose of this article is to discuss new approaches to performance management in health care services when the purpose is to support innovative changes in the delivery of services. DESIGN/METHODOLOGY/APPROACH The article represents cross-boundary work as the theoretical and empirical material used to discuss and reconsider performance management comes from several relevant research disciplines, including systematic reviews of audit and feedback interventions in health care and extant theories of human motivation and organizational control. FINDINGS An enabling approach to performance management in health care services can potentially contribute to innovative changes. Key design elements to operationalize such an approach are a formative and learning-oriented use of performance measures, an appeal to self- and social-approval mechanisms when providing feedback and support for local goals and action plans that fit specific conditions and challenges. ORIGINALITY/VALUE The article suggests how to operationalize an enabling approach to performance management in health care services. The framework is consistent with new governance and managerial approaches emerging in public sector organizations more generally, supporting a higher degree of professional autonomy and the use of nonfinancial incentives.
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Affiliation(s)
- Anell Anders
- Department of Business Administration, Lund University
School of Economics and Management, Lund, Sweden
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Jamili S, Yousefi M, Pour HE, Houshmand E, Taghipour A, Tabatabaee SS, Adel A. Comparison of pay-for-performance (P4P) programs in primary care of selected countries: a comparative study. BMC Health Serv Res 2023; 23:865. [PMID: 37580717 PMCID: PMC10426118 DOI: 10.1186/s12913-023-09841-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 07/22/2023] [Indexed: 08/16/2023] Open
Abstract
BACKGROUND Pay for performance (P4P) schemes provide financial incentives or facilities to health workers based on the achievement of predetermined performance goals. Various P4P programs have been implemented around the world. There is a question of which model is suitable for p4p implementation to achieve better results. The purpose of this study is to compare pay for performance models in different countries. METHODS This is a descriptive-comparative study comparing the P4P model in selected countries in 2022. Data for each country are collected from reliable databases and are tabulated to compare their payment models. the standard framework of the P4P model is used for data analysis. RESULTS we used the standard P4P model framework to compare pay for performance programs in the primary care sector of selected countries because this framework can demonstrate all the necessary features of payment programs, including performance domains and measures, basis for reward or penalty, nature of the reward or penalty, and data reporting. The results of this study show that although the principles of P4P are almost similar in the selected countries, the biggest difference is in the definition of performance domains and measures. CONCLUSIONS Designing an effective P4P program is very complex, and its success depends on a variety of factors, from the socioeconomic and cultural context and the healthcare goals of governments to the personal characteristics of the healthcare provider. considering these factors and the general framework of the features of P4P programs are critical to the success of the p4p design and implementation.
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Affiliation(s)
- Sara Jamili
- Student Research Committee, Department of Health Economics and Management Sciences, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mehdi Yousefi
- Department of Health Economics and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran.
| | - Hossein Ebrahimi Pour
- Department of Health Economics and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Elahe Houshmand
- Department of Health Economics and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Taghipour
- Department of Epidemiology and Biostatistics, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Seyed Saeed Tabatabaee
- Department of Health Economics and Management, School of Health, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Amin Adel
- Health Management and Economics Research Center, Iran University of Medical Sciences, Tehran, Iran
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Rasooly A, Pan Y, Tang Z, Jiangjiang H, Ellen ME, Manor O, Hu S, Davidovitch N. Quality and Performance Measurement in Primary Diabetes Care: A Qualitative Study in Urban China. Int J Health Policy Manag 2022; 11:3019-3031. [PMID: 35942954 PMCID: PMC10105207 DOI: 10.34172/ijhpm.2022.6372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 05/17/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Quality measurements in primary healthcare (PHC) have become an essential component for improving diabetes outcomes in many high-income countries. However, little is known about their implementation within the Chinese health-system context and how they are perceived by patients, physicians, and policy-makers. We examined stakeholders' perceptions of quality and performance measurements for primary diabetes care in Shanghai, China, and analyzed facilitators and barriers to implementation. METHODS In-depth interviews with 26 key stakeholders were conducted from 2018 to 2019. Participants were sampled from two hospitals, four community healthcare centers (CHCs), and four institutes involved in regulating CHCs. The Consolidated Framework for Implementation Research (CFIR) guided data analysis. RESULTS Existing quality measurements were uniformly implemented via a top-down process, with daily monitoring of family doctors' work and pay-for-performance incentives. Barriers included excluding frontline clinicians from indicator planning, a lack of transparent reporting, and a rigid organizational culture with limited bottom-up feedback. Findings under the CFIR construct "organizational incentives" suggested that current pay-for-performance incentives function as a "double-edged sword," increasing family doctors' motivation to excel while creating pressures to "game the system" among some physicians. When considering the CFIR construct "reflecting and evaluating," policy-makers perceived the online evaluation application - which provides daily reports on family doctors' work - to be an essential tool for improving quality; however, this information was not visible to patients. Findings included under the "network and communication" construct showed that specialists support the work of family doctors by providing training and patient consultations in CHCs. CONCLUSION The quality of healthcare could be considerably enhanced by involving patients and physicians in decisions on quality measurement. Strengthening hospital-community partnerships can improve the quality of primary care in hospital-centric systems. The case of Shanghai provides compelling policy lessons for other health systems faced with the challenge of improving PHC.
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Affiliation(s)
- Alon Rasooly
- School of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Yancen Pan
- Department of Epidemiology, Fielding School of Public Health, University of California, Los Angeles, CA, USA
| | - Zhenqing Tang
- Shanghai Health Development Research Center, Shanghai, China
| | - He Jiangjiang
- Shanghai Health Development Research Center, Shanghai, China
| | - Moriah E. Ellen
- School of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Orly Manor
- Braun School of Public Health and Community Medicine, Hebrew University, Jerusalem, Israel. 5 School of Public Health, Fudan University, Shanghai, China
| | - Shanlian Hu
- School of Public Health, Fudan University, Shanghai, China
| | - Nadav Davidovitch
- School of Public Health, Ben-Gurion University of the Negev, Beer Sheva, Israel
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Kim W, Koo H, Lee HJ, Han E. The Effects of Cost Containment and Price Policies on Pharmaceutical Expenditure in South Korea. Int J Health Policy Manag 2022; 11:2198-2207. [PMID: 34814666 PMCID: PMC9808296 DOI: 10.34172/ijhpm.2021.135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 09/19/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Policy-makers have proposed and implemented various cost-containment policies for drug prices and quantities to regulate rising pharmaceutical spending. Our study focused on a major change in pricing policy and several incentive schemes for curbing pharmaceutical expenditure growth during the 2010s in Korea. METHODS We constructed the longitudinal dataset from 2008-2017 for 12 904 clinics to track the prescriber behavior before and after the implemented policies. Applying an interrupted time series model, we analyzed changes in trends in overall monthly drug expenditure and antibiotic drug expenditure per prescription for outpatient claims diagnosed with three major diseases before and after the policies' implementation. RESULTS Significant price reductions and incentives for more efficient drug prescriptions resulted in an immediate decrease in monthly drug expenditures in clinics. However, we found attenuated effects over the long run. The top-spending clinics showed the highest rate of increase in drug costs. CONCLUSION Future policy interventions can maximize their effects by targeting high-spending providers.
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Affiliation(s)
- Woohyeon Kim
- Korea Institute of Public Finance, Sejong, South Korea
| | - Heejo Koo
- College of Pharmacy, Yonsei Institute of Pharmaceutical Research, Yonsei University, Seoul, South Korea
| | - Hye-Jae Lee
- College of Pharmacy, Woosuk University, Wanju, South Korea
| | - Euna Han
- College of Pharmacy, Yonsei Institute of Pharmaceutical Research, Yonsei University, Seoul, South Korea
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Li X, Evans JM. Incentivizing performance in health care: a rapid review, typology and qualitative study of unintended consequences. BMC Health Serv Res 2022; 22:690. [PMID: 35606747 PMCID: PMC9128153 DOI: 10.1186/s12913-022-08032-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 05/04/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Health systems are increasingly implementing policy-driven programs to incentivize performance using contracts, scorecards, rankings, rewards, and penalties. Studies of these "Performance Management" (PM) programs have identified unintended negative consequences. However, no single comprehensive typology of the negative and positive unintended consequences of PM in healthcare exists and most studies of unintended consequences were conducted in England or the United States. The aims of this study were: (1) To develop a comprehensive typology of unintended consequences of PM in healthcare, and (2) To describe multiple stakeholder perspectives of the unintended consequences of PM in cancer and renal care in Ontario, Canada. METHODS We conducted a rapid review of unintended consequences of PM in healthcare (n = 41 papers) to develop a typology of unintended consequences. We then conducted a secondary analysis of data from a qualitative study involving semi-structured interviews with 147 participants involved with or impacted by a PM system used to oversee 40 care delivery networks in Ontario, Canada. Participants included administrators and clinical leads from the networks and the government agency managing the PM system. We undertook a hybrid inductive and deductive coding approach using the typology we developed from the rapid review. RESULTS We present a comprehensive typology of 48 negative and positive unintended consequences of PM in healthcare, including five novel unintended consequences not previously identified or well-described in the literature. The typology is organized into two broad categories: unintended consequences on (1) organizations and providers and on (2) patients and patient care. The most common unintended consequences of PM identified in the literature were measure fixation, tunnel vision, and misrepresentation or gaming, while those most prominent in the qualitative data were administrative burden, insensitivity, reduced morale, and systemic dysfunction. We also found that unintended consequences of PM are often mutually reinforcing. CONCLUSIONS Our comprehensive typology provides a common language for discourse on unintended consequences and supports systematic, comparable analyses of unintended consequences across PM regimes and healthcare systems. Healthcare policymakers and managers can use the results of this study to inform the (re-)design and implementation of evidence-informed PM programs.
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Affiliation(s)
- Xinyu Li
- Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | - Jenna M Evans
- DeGroote School of Business, McMaster University, 1280 Main Street West, Hamilton, ON, L8S4M4, Canada.
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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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McGrath N, Riordan F, Kearney PM, O'Neill K, McHugh SM. Health professionals’ views of the first national GP payment scheme for structured type 2 diabetes care in Ireland: a qualitative study. HRB Open Res 2021. [DOI: 10.12688/hrbopenres.13460.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Background: Payment schemes are widely used to improve chronic disease management in general practice. Although stakeholder views of such schemes could provide valuable learning regarding aspects that work and those which are more difficult to implement, there is a paucity of such data. We explored health professionals’ views of the implementation of the first national general practice payment scheme for type 2 diabetes (T2DM) care in Ireland, the ‘cycle of care’. Methods: Qualitative data were drawn from a multiple case study evaluating the implementation of a National Clinical Programme for Diabetes, collected from April 2016 to June 2017. Interview and focus group transcripts from participants involved in providing diabetes management in general practice and who referenced the cycle of care were eligible for inclusion in the current analysis. Data were analysed using reflective thematic analysis. Results: We analysed data from 28 participants comprising general practitioners (GPs) (n=8), practice nurses (n=9) and diabetes nurse specialists (DNS) (n=11). Participants perceived the cycle of care as “not adequate, but…a good start” to improve T2DM care in general practice in Ireland. Perceived benefits were greater financial viability for T2DM management in general practice, fostering a more proactive approach to T2DM care, delivery of T2DM care closer to patients’ homes, and increased use of other community diabetes services e.g., DNS and podiatry. Participants identified the limited resource for practice nurse time, inflexibility to provide care based on patient need and issues with data submission as drawbacks of the cycle of care. Conclusions: The cycle of care was viewed as a positive first step to increase and improve T2DM care delivered in general practice in Ireland. The implementation issues identified in this study should be considered in the design of future payment schemes targeting chronic disease management in general practice.
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Melby L, Håland E. When time matters: a qualitative study on hospital staff's strategies for meeting the target times in cancer patient pathways. BMC Health Serv Res 2021; 21:210. [PMID: 33750379 PMCID: PMC7941937 DOI: 10.1186/s12913-021-06224-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 02/28/2021] [Indexed: 12/22/2022] Open
Abstract
Background Cancer patient pathways (CPPs) were introduced in Norway in 2015. CPPs are time-bound standardised care pathways that describe the organisation of and responsibilities for diagnostics and treatment, as well as communication with the patient and next of kin. The aim is to ensure that cancer patients experience a well-organised, coherent and predictable pathway without any delays in assessment and diagnostics caused by non-medical reasons. Preventing delays in diagnostics by meeting specific target times is central to the successful implementation of CPPs. The aim of this paper is to describe how hospital staff cope with the increased focus on meeting CPP target times and the measures and strategies implemented by hospitals and their staff. Methods Data for this paper were collected in a larger study on implementation and experiences with CPPs among hospital staff, general practitioners, and patients in Norway (2017–2020). The study had a qualitative cross-sectional design, and data were collected through interviews. This article is based on semi-structured interviews with hospital staff (N = 60) in five hospitals. Results Hospital staff are highly aware of the target times, and try to comply with them, in the interest of both the patients and the hospitals. The implementation of CPPs was not accompanied by the allocation of additional resources; therefore, hospitals could not simply increase capacity to meet the target times. Instead, they had to develop other strategies. Four categories of strategies were identified: (i) introducing new roles and more staff, (ii) reorganising the workflow, (iii) gaming the system and (iv) outsourcing services. Conclusions Hospital staff are torn between meeting the target times and a lack of resources and capacity. This is not unusual in the current healthcare context, where staff face organisational reforms and increasing demands on a regular basis. It is important to recognise frontline workers’ efforts towards realising new organisational changes. Therefore, carefully weighing the benefits against the costs and undertaking the necessary planning are important in the design and implementation of future care and treatment pathways for patients.
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Affiliation(s)
- Line Melby
- Department of Health Research, SINTEF, P.O. Box 4760, Torgarden, 7465, Trondheim, Norway.
| | - Erna Håland
- Norwegian University of Science and Technology, 7491, Trondheim, Norway
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Explaining health system responses to public reporting of cardiac surgery mortality in England and the USA. HEALTH ECONOMICS POLICY AND LAW 2021; 16:183-200. [PMID: 33455616 DOI: 10.1017/s1744133120000444] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Public reporting of clinical performance is increasingly used in many countries to improve quality and enhance accountability of the health system. The assumption is that greater transparency will stimulate improvements by clinicians in response to peer pressure, patient choice or competition. The international diffusion of public reporting might suggest greater similarity between health systems. Alternatively, national and local contexts (including health system imperatives, professional power and organisational culture) might continue to shape its form and impact, implying continued divergence. The paper considers public reporting in the USA and England through the lens of Scott's 'pillars' institutional framework. The USA was arguably the first country to adopt public reporting systematically in the late 1980s. England is a more recent adopter; it is now being widely adopted through the National Health Service (NHS). Drawing on qualitative data from California and England, this paper compares the behavioural and policy responses to public reporting by health system stakeholders at micro, meso and macro levels and through the intersection of ideas, interests, institutions and individuals through. The interplay between the regulative, normative and cultural-cognitive pillars helps explain the observed patterns of on-going divergence.
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Khan N, Rudoler D, McDiarmid M, Peckham S. A pay for performance scheme in primary care: Meta-synthesis of qualitative studies on the provider experiences of the quality and outcomes framework in the UK. BMC FAMILY PRACTICE 2020; 21:142. [PMID: 32660427 PMCID: PMC7359468 DOI: 10.1186/s12875-020-01208-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 06/23/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND The Quality and Outcomes Framework (QOF) is an incentive scheme for general practice, which was introduced across the UK in 2004. The Quality and Outcomes Framework is one of the biggest pay for performance (P4P) scheme in the world, worth £691 million in 2016/17. We now know that P4P is good at driving some kinds of improvement but not others. In some areas, it also generated moral controversy, which in turn created conflicts of interest for providers. We aimed to undertake a meta-synthesis of 18 qualitative studies of the QOF to identify themes on the impact of the QOF on individual practitioners and other staff. METHODS We searched 5 electronic databases, Medline, Embase, Healthstar, CINAHL and Web of Science, for qualitative studies of the QOF from the providers' perspective in primary care, published in UK between 2004 and 2018. Data was analysed using the Schwartz Value Theory as a theoretical framework to analyse the published papers through the conceptual lens of Professionalism. A line of argument synthesis was undertaken to express the synthesis. RESULTS We included 18 qualitative studies that where on the providers' perspective. Four themes were identified; 1) Loss of autonomy, control and ownership; 2) Incentivised conformity; 3) Continuity of care, holism and the caring role of practitioners' in primary care; and 4) Structural and organisational changes. Our synthesis found, the Values that were enhanced by the QOF were power, achievement, conformity, security, and tradition. The findings indicated that P4P schemes should aim to support Values such as benevolence, self-direction, stimulation, hedonism and universalism, which professionals ranked highly and have shown to have positive implications for Professionalism and efficiency of health systems. CONCLUSIONS Understanding how practitioners experience the complexities of P4P is crucial to designing and delivering schemes to enhance and not compromise the values of professionals. Future P4P schemes should aim to permit professionals with competing high priority values to be part of P4P or other quality improvement initiatives and for them to take on an 'influencer role' rather than being 'responsive agents'. Through understanding the underlying Values and not just explicit concerns of professionals, may ensure higher levels of acceptance and enduring success for P4P schemes.
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Affiliation(s)
| | - David Rudoler
- Faculty of Health Sciences, University of Ontario Institute of Technology, 2000 Simcoe Street North, Unit UA3000, Oshawa, ON, L1H 7K4, Canada
| | - Mary McDiarmid
- Ontario Shores Centre for Mental Health Sciences, 700 Gordon Street, Whitby, ON, L1N 5S9, Canada
| | - Stephen Peckham
- Centre for Health Services Studies, University of Kent, Kent, Canterbury, CT2 7NF, UK
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Jan CF, Lee MC, Chiu CM, Huang CK, Hwang SJ, Chang CJ, Chiu TY. Awareness of, attitude toward, and willingness to participate in pay for performance programs among family physicians: a cross-sectional study. BMC FAMILY PRACTICE 2020; 21:60. [PMID: 32228473 PMCID: PMC7106702 DOI: 10.1186/s12875-020-01118-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/25/2019] [Accepted: 02/26/2020] [Indexed: 01/02/2023]
Abstract
Background The National Health Insurance Administration of Taiwan has introduced several pay-for-performance programs to improve the quality of healthcare. This study aimed to provide government with evidence-based research findings to help primary care physicians to actively engage in pay-for-performance programs. Methods We conducted a questionnaire survey among family physicians with age-stratified sampling from September 2016 to December 2017. The structured questionnaire consisted of items including the basic demographics of the surveyee and their awareness of and attitudes toward the strengths and/or weaknesses of the pay-for-performance programs, as well as their subjective norms, and the willingness to participate in the pay-for-performance programs. Univariate analysis and multivariate logistic regression analysis were performed to compare the differences between family physicians who participate in the pay-for-performance programs versus those who did not. Results A total of 543 family physicians completed the questionnaire. Among family physicians who participated in the pay-for-performance programs, more had joined the Family Practice Integrated Care Project [Odds ratio (OR): 2.70; 95% Confidence interval (CI): 1.78 ~ 4.09], had a greater awareness of pay-for-performance programs (OR: 2.37; 95% CI: 1.50 ~ 3.83), and a less negative attitude to pay-for-performance programs (OR: 0.50; 95% CI: 0.31 ~ 0.80) after adjusting for age and gender. The major reasons for family physicians who decided to join the pay-for-performance programs included believing the programs help enhance the quality of healthcare (80.8%) and recognizing the benefit of saving health expenditure (63.4%). The causes of unwillingness to join in a pay-for-performance program among non-participants were increased load of administrative works (79.6%) and inadequate understanding of the contents of the pay-for-performance programs (62.9%). Conclusions To better motivate family physicians into P4P participation, hosting effective training programs, developing a more transparent formula for assessing financial risk, providing sufficient budget for healthcare quality improvement, and designing a reasonable profit-sharing plan to promote collaboration between different levels of medical institutions are all imperative.
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Affiliation(s)
- Chyi-Feng Jan
- Department of Family Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No.7, Chung-Shan South Road, 10002, Taipei, Taiwan
| | - Meng-Chih Lee
- Department of Family Medicine, Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan.,Chinese Taipei (Taiwan) Association of Family Medicine, Taipei, Taiwan
| | - Ching-Ming Chiu
- Department of Family Medicine, National Taiwan University Hospital, Yunlin Branch, Taipei, Yunlin, Taiwan
| | - Cheng-Kuo Huang
- Chinese Taipei (Taiwan) Association of Family Medicine, Taipei, Taiwan.,Keelung Medical Association, Keelung, Taiwan
| | - Shinn-Jang Hwang
- Chinese Taipei (Taiwan) Association of Family Medicine, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan.,Taipei Veterans General Hospital, Taipei, Taiwan
| | - Che-Jui Chang
- Department of Family Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No.7, Chung-Shan South Road, 10002, Taipei, Taiwan
| | - Tai-Yuan Chiu
- Department of Family Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, No.7, Chung-Shan South Road, 10002, Taipei, Taiwan. .,Chinese Taipei (Taiwan) Association of Family Medicine, Taipei, Taiwan.
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Barsanti S, Vola F, Bonciani M. Trade union or trait d'union? Setting targets for general practitioners: A regional case study. Int J Health Plann Manage 2020; 35:262-279. [DOI: 10.1002/hpm.2903] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 09/04/2019] [Accepted: 09/05/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Sara Barsanti
- Institute of Management, Laboratorio Management e SanitàScuola Superiore Sant'Anna di Pisa Pisa Italy
| | - Federico Vola
- Institute of Management, Laboratorio Management e SanitàScuola Superiore Sant'Anna di Pisa Pisa Italy
| | - Manila Bonciani
- Institute of Management, Laboratorio Management e SanitàScuola Superiore Sant'Anna di Pisa Pisa Italy
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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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An Analysis of Pay-for-Performance Schemes and Their Potential Impacts on Health Systems and Outcomes for Patients. Crit Care Res Pract 2019; 2019:8943972. [PMID: 31321097 PMCID: PMC6607710 DOI: 10.1155/2019/8943972] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 05/29/2019] [Accepted: 06/02/2019] [Indexed: 01/17/2023] Open
Abstract
Pay-for-performance (P4P) programs have been introduced into the Canadian medical system in the last decades. This paper examines the underlying characteristics of P4P and describes both their advantages and drawbacks. Most P4P programs provide the advantage of rewarding medical acts, thus providing an incentive to take on complex patients. There is a variety of nuanced P4P initiatives, which provide financial incentive according to differing criteria, based on quality measures, incentives, and/or benchmark structures. However, there is no conclusive evidence demonstrating that P4P programs provide better value for money than traditional pay schemes, regardless of particular structural choices. Some evidence has even shown that P4P may be detrimental, especially in disadvantaged and high-risk populations. Additionally, there are a number of ethical and practical concerns that arise with the use of P4P, such as the risk of financial incentives being misused or misinterpreted and patients being refused or referred during treatment. P4P initiatives require careful examination and the creation of solid, evidence-based criteria for evaluation and implementation in Canadian medical systems.
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Etz RS, Zyzanski SJ, Gonzalez MM, Reves SR, O'Neal JP, Stange KC. A New Comprehensive Measure of High-Value Aspects of Primary Care. Ann Fam Med 2019; 17:221-230. [PMID: 31085526 PMCID: PMC6827628 DOI: 10.1370/afm.2393] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 03/18/2019] [Accepted: 03/21/2019] [Indexed: 11/09/2022] Open
Abstract
PURPOSE To develop and evaluate a concise measure of primary care that is grounded in the experience of patients, clinicians, and health care payers. METHODS We asked crowd-sourced samples of 412 patients, 525 primary care clinicians, and 85 health care payers to describe what provides value in primary care, then asked 70 primary care and health services experts in a 2½ day international conference to provide additional insights. A multidisciplinary team conducted a qualitative analysis of the combined data to develop a parsimonious set of patient-reported items. We evaluated items using factor analysis, Rasch modeling, and association analyses among 2 online samples and 4 clinical samples from diverse patient populations. RESULTS The resulting person-centered primary care measure parsimoniously represents the broad scope of primary care, with 11 domains each represented by a single item: accessibility, advocacy, community context, comprehensiveness, continuity, coordination, family context, goal-oriented care, health promotion, integration, and relationship. Principal axes factor analysis identified a single factor. Factor loadings and corrected item-total correlations were >0.6 in online samples (n = 2,229) and >0.5 in clinical samples (n = 323). Factor scores were fairly normally distributed in online patient samples, and skewed toward higher ratings in point-of-care patient samples. Rasch models showed a broad spread of person and item scores, acceptable item-fit statistics, and little item redundancy. Preliminary concurrent validity analyses supported hypothesized associations. CONCLUSIONS The person-centered primary care measure reliably, comprehensively, and parsimoniously assesses the aspects of care thought to represent high-value primary care by patients, clinicians, and payers. The measure is ready for further validation and outcome analyses, and for use in focusing attention on what matters about primary care, while reducing measurement burden.
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Affiliation(s)
- Rebecca S Etz
- Larry A. Green Center for the Advancement of Primary Health Care for the Public Good .,Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Stephen J Zyzanski
- Center for Community Health Integration, Departments of Family Medicine & Community Health, Population & Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio
| | - Martha M Gonzalez
- Larry A. Green Center for the Advancement of Primary Health Care for the Public Good.,Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Sarah R Reves
- Larry A. Green Center for the Advancement of Primary Health Care for the Public Good.,Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Jonathan P O'Neal
- Larry A. Green Center for the Advancement of Primary Health Care for the Public Good.,Department of Family Medicine and Population Health, Virginia Commonwealth University, Richmond, Virginia
| | - Kurt C Stange
- Larry A. Green Center for the Advancement of Primary Health Care for the Public Good.,Center for Community Health Integration, Departments of Family Medicine & Community Health, Population & Quantitative Health Sciences, Case Western Reserve University, Cleveland, Ohio.,Departments of General Medical Sciences and Sociology, and Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, Ohio
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Brown B, Gude WT, Blakeman T, van der Veer SN, Ivers N, Francis JJ, Lorencatto F, Presseau J, Peek N, Daker-White G. Clinical Performance Feedback Intervention Theory (CP-FIT): a new theory for designing, implementing, and evaluating feedback in health care based on a systematic review and meta-synthesis of qualitative research. Implement Sci 2019; 14:40. [PMID: 31027495 PMCID: PMC6486695 DOI: 10.1186/s13012-019-0883-5] [Citation(s) in RCA: 153] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Accepted: 03/25/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Providing health professionals with quantitative summaries of their clinical performance when treating specific groups of patients ("feedback") is a widely used quality improvement strategy, yet systematic reviews show it has varying success. Theory could help explain what factors influence feedback success, and guide approaches to enhance effectiveness. However, existing theories lack comprehensiveness and specificity to health care. To address this problem, we conducted the first systematic review and synthesis of qualitative evaluations of feedback interventions, using findings to develop a comprehensive new health care-specific feedback theory. METHODS We searched MEDLINE, EMBASE, CINAHL, Web of Science, and Google Scholar from inception until 2016 inclusive. Data were synthesised by coding individual papers, building on pre-existing theories to formulate hypotheses, iteratively testing and improving hypotheses, assessing confidence in hypotheses using the GRADE-CERQual method, and summarising high-confidence hypotheses into a set of propositions. RESULTS We synthesised 65 papers evaluating 73 feedback interventions from countries spanning five continents. From our synthesis we developed Clinical Performance Feedback Intervention Theory (CP-FIT), which builds on 30 pre-existing theories and has 42 high-confidence hypotheses. CP-FIT states that effective feedback works in a cycle of sequential processes; it becomes less effective if any individual process fails, thus halting progress round the cycle. Feedback's success is influenced by several factors operating via a set of common explanatory mechanisms: the feedback method used, health professional receiving feedback, and context in which feedback takes place. CP-FIT summarises these effects in three propositions: (1) health care professionals and organisations have a finite capacity to engage with feedback, (2) these parties have strong beliefs regarding how patient care should be provided that influence their interactions with feedback, and (3) feedback that directly supports clinical behaviours is most effective. CONCLUSIONS This is the first qualitative meta-synthesis of feedback interventions, and the first comprehensive theory of feedback designed specifically for health care. Our findings contribute new knowledge about how feedback works and factors that influence its effectiveness. Internationally, practitioners, researchers, and policy-makers can use CP-FIT to design, implement, and evaluate feedback. Doing so could improve care for large numbers of patients, reduce opportunity costs, and improve returns on financial investments. TRIAL REGISTRATION PROSPERO, CRD42015017541.
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Affiliation(s)
- Benjamin Brown
- Centre for Health Informatics, University of Manchester, Manchester, UK
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Wouter T. Gude
- Department of Medical Informatics, Amsterdam University Medical Centres, Amsterdam, The Netherlands
| | - Thomas Blakeman
- Centre for Primary Care, University of Manchester, Manchester, UK
| | | | - Noah Ivers
- Department of Family and Community Medicine, University of Toronto, Toronto, Canada
| | - Jill J. Francis
- Centre for Health Services Research, City University of London, London, UK
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - Justin Presseau
- Centre for Implementation Research, Ottawa Hospital Research Institute, Ottawa, Canada
- School of Epidemiology & Public Health, University of Ottawa, Ottawa, Canada
- School of Psychology, University of Ottawa, Ottawa, Canada
| | - Niels Peek
- Centre for Health Informatics, University of Manchester, Manchester, UK
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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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Incentive schemes to increase dementia diagnoses in primary care in England: a retrospective cohort study of unintended consequences. Br J Gen Pract 2019; 69:e154-e163. [PMID: 30803980 DOI: 10.3399/bjgp19x701513] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2018] [Accepted: 08/27/2018] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The UK government introduced two financial incentive schemes for primary care to tackle underdiagnosis in dementia: the 3-year Directed Enhanced Service 18 (DES18) and the 6-month Dementia Identification Scheme (DIS). The schemes appear to have been effective in boosting dementia diagnosis rates, but their unintended effects are unknown. AIM To identify and quantify unintended consequences associated with the DES18 and DIS schemes. DESIGN AND SETTING A retrospective cohort quantitative study of 7079 English primary care practices. METHOD Potential unintended effects of financial incentive schemes, both positive and negative, were identified from a literature review. A practice-level dataset covering the period 2006/2007 to 2015/2016 was constructed. Difference-in-differences analysis was employed to test the effects of the incentive schemes on quality measures from the Quality and Outcomes Framework (QOF); and four measures of patient experience from the GP Patient Survey (GPPS): patient-centred care, access to care, continuity of care, and the doctor-patient relationship. The researchers controlled for effects of the contemporaneous hospital incentive scheme for dementia and for practice characteristics. RESULTS National practice participation rates in DES18 and DIS were 98.5% and 76% respectively. Both schemes were associated not only with a positive impact on QOF quality outcomes, but also with negative impacts on some patient experience indicators. CONCLUSION The primary care incentive schemes for dementia appear to have enhanced QOF performance for the dementia review, and have had beneficial spillover effects on QOF performance in other clinical areas. However, the schemes may have had negative impacts on several aspects of patient experience.
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Abstract
Abstract
This paper explores how general practitioners (GPs) address potentially opposing motivations stemming from being altruistic and self-interested, and the implications for patients and GPs. The author finds that GPs address dual goals of patient care and profit generation. This can be challenging, while professional values (altruism) encourage a patient focus, business realities (self-interest) mandate other priorities. Viewing clinicians as altruistic in isolation of business needs is unrealistic, as is the notion that profit is the dominant motivation. A blending of interests occurs, pursuing reasonable self-interest, patients’ best interests are ultimately met. GPs need a profit focus to sustain/improve the practice, benefitting patients through continued availability and capacity for enhancement. Therefore, it is argued that GPs behave in a manner that is ‘part altruistic, part self-interested’ and mutually beneficial. These insights should be considered in designing incentive systems for GPs, raising compelling questions about contemporary understanding of the nature of professionals.
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Abstract
Abstract
Behavioral economics seeks to define how humans respond to incentives, how to maximize desired behavioral change, and how to avoid perverse negative impacts on work effort. Relatively new in their application to physician behavior, behavioral economic principles have primarily been used to construct optimized financial incentives. This review introduces and evaluates the essential components of building successful financial incentive programs for physicians, adhering to the principles of behavioral economics. Referencing conceptual publications, observational studies, and the relatively sparse controlled studies, the authors offer physician leaders, healthcare administrators, and practicing anesthesiologists the issues to consider when designing physician incentive programs to maximize effectiveness and minimize unintended consequences.
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Wallace E, Johansen ME. Clinical Prediction Rules: Challenges, Barriers, and Promise. Ann Fam Med 2018; 16:390-392. [PMID: 30201634 PMCID: PMC6130996 DOI: 10.1370/afm.2303] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 08/14/2018] [Accepted: 08/14/2018] [Indexed: 12/20/2022] Open
Affiliation(s)
- Emma Wallace
- Department of General Practice, Royal College of Surgeons in Ireland (RCSI), Dublin, Ireland
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22
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Aron DC, Tseng CL, Soroka O, Pogach LM. Balancing measures: identifying unintended consequences of diabetes quality performance measures in patients at high risk for hypoglycemia. Int J Qual Health Care 2018; 31:246-251. [DOI: 10.1093/intqhc/mzy151] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 05/10/2018] [Accepted: 06/20/2018] [Indexed: 12/14/2022] Open
Affiliation(s)
- David C Aron
- Medical Service, Louis Stokes Cleveland VA Medical Center, Cleveland, OH, USA
- Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Chin-Lin Tseng
- Research Service, Department of Veterans Affairs-New Jersey Healthcare System, East Orange, NJ, USA
| | - Orysya Soroka
- Research Service, Department of Veterans Affairs-New Jersey Healthcare System, East Orange, NJ, USA
| | - Leonard M Pogach
- Office of Specialty Care Services, Department of Veterans Affairs, Washington, DC, USA
- Department of Medicine, Rutgers New Jersey School of Medicine, Newark, NJ, USA
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Brazil's National Program for Improving Primary Care Access and Quality (PMAQ): Fulfilling the Potential of the World's Largest Payment for Performance System in Primary Care. J Ambul Care Manage 2018; 40 Suppl 2 Supplement, The Brazilian National Program for Improving Primary Care Access and Quality (PMAQ):S4-S11. [PMID: 28252498 PMCID: PMC5338882 DOI: 10.1097/jac.0000000000000189] [Citation(s) in RCA: 46] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Despite some remarkable achievements, there are several challenges facing Brazil's Family Health Strategy (FHS), including expanding access to primary care and improving its quality. These concerns motivated the development of the National Program for Improving Primary Care Access and Quality (PMAQ). Although voluntary, the program now includes nearly 39 000 FHS teams in the country and has led to a near doubling of the federal investment in primary care in its first 2 rounds. In this article, we introduce the PMAQ and advance several recommendations to ensure that it continues to improve primary care access and quality in Brazil.
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Missing performance management and measurement aspects in performance-based contracting. INTERNATIONAL JOURNAL OF OPERATIONS & PRODUCTION MANAGEMENT 2018. [DOI: 10.1108/ijopm-09-2016-0571] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose
Performance-based contracting (PBC) is a business model for the adaptive and innovative delivery of product-service systems. In PBC, the provider is paid according to the service performance with the aim of providing monetary incentives to safeguard possible outcomes as much as possible for the PBC customer. Performance measurement and its management are crucial for PBC success and, in particular, for the pay-for-performance link. However, the literature on PBC performance management is rather sparse, and there has been no systematic review on the topic. Thus, the purpose of this paper is to fill that gap and to present a comprehensive and systematic review of performance measurement and management in the PBC context.
Design/methodology/approach
The paper builds on a literature review based on a sample of 102 subject-relevant articles from academic journals. The content analysis follows a two-step procedure. First, the articles are coded following a process-based research framework. Second, the content of each process step is assessed in a qualitative text analysis.
Findings
The results show a surprising scarcity of papers that explicitly address performance management topics in the context of PBC. Only the topics of performance specification and performance indicators are broadly addressed, whereas in all of the other areas, e.g., strategic alignment, data capture and reporting, only limited specific findings could be found.
Research limitations/implications
The paper concludes that future research on performance management in PBC should expand its theoretical framework and empirical efforts in four specific proposed directions.
Originality/value
The paper provides an up-to-date review that is focused on performance management and measurement in the emerging context of PBC.
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Reports of unintended consequences of financial incentives to improve management of hypertension. PLoS One 2017; 12:e0184856. [PMID: 28934258 PMCID: PMC5608267 DOI: 10.1371/journal.pone.0184856] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2016] [Accepted: 09/01/2017] [Indexed: 12/17/2022] Open
Abstract
Background Given the increase in financial-incentive programs nationwide, many physicians and physician groups are concerned about potential unintended consequences of providing financial incentives to improve quality of care. However, few studies examine whether actual unintended consequences result from providing financial incentives to physicians. We sought to document the extent to which the unintended consequences discussed in the literature were observable in a randomized clinical trial (RCT) of financial incentives. Methods We conducted a qualitative observational study nested within a larger RCT of financial incentives to improve hypertension care. We conducted 30-minute telephone interviews with primary care personnel at facilities participating in the RCT housed at12 geographically dispersed Veterans Affairs Medical Centers nationwide. Participants answered questions about unintended effects, clinic team dynamics, organizational impact on care delivery, study participation. We employed a blend of inductive and deductive qualitative techniques for analysis. Participants Sixty-five participants were recruited from RCT enrollees and personnel not enrolled in the larger RCT, plus one primary care leader per site. Results Emergent themes included possible patient harm, emphasis on documentation over improving care, reduced professional morale, and positive spillover. All discussions of unintended consequences involving patient harm were only concerns, not actual events. Several unintended consequences concerned ancillary initiatives for quality improvement (e.g., practice guidelines and performance measurement systems) rather than financial incentives. Conclusions Many unintended consequences of financial incentives noted were either only concerns or attributable to ancillary quality-improvement initiatives. Actual unintended consequences included improved documentation of care without necessarily improving actual care, and positive unintended consequences. Trial registration Clinicaltrials.gov Identifier: NCT00302718
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Korownyk C, McCormack J, Kolber MR, Garrison S, Michael Allan G. [Not Available]. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2017; 63:e371-e376. [PMID: 28904046 PMCID: PMC5597026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Christina Korownyk
- Professeure agrégée au Département de médecine familiale de l'Université de l'Alberta à Edmonton.
| | - James McCormack
- Professeur à la Faculté des sciences pharmaceutiques de l'Université de la Colombie-Britannique à Vancouver
| | - Michael R Kolber
- Professeur agrégé au Département de médecine familiale de l'Université de l'Alberta
| | - Scott Garrison
- Professeur agrégé au Département de médecine familiale de l'Université de l'Alberta
| | - G Michael Allan
- Professeur et directeur de la Médecine fondée sur des données probantes à l'Université de l'Alberta
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Korownyk C, McCormack J, Kolber MR, Garrison S, Allan GM. Competing demands and opportunities in primary care. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2017; 63:664-668. [PMID: 28904027 PMCID: PMC5597006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- Christina Korownyk
- Associate Professor in the Department of Family Medicine at the University of Alberta in Edmonton.
| | - James McCormack
- Professor in the Faculty of Pharmaceutical Sciences at the University of British Columbia in Vancouver
| | - Michael R Kolber
- Associate Professor in the Department of Family Medicine at the University of Alberta
| | - Scott Garrison
- Associate Professor in the Department of Family Medicine at the University of Alberta
| | - G Michael Allan
- Professor and Director of Evidence-Based Medicine in the Department of Family Medicine at the University of Alberta
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Jones EJ, Eikner D, Coleman CM. NFPRHA commentary on the contraceptive care performance measures. Contraception 2017; 96:145-148. [PMID: 28711644 DOI: 10.1016/j.contraception.2017.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Revised: 06/29/2017] [Accepted: 07/02/2017] [Indexed: 10/19/2022]
Affiliation(s)
- Elizabeth J Jones
- National Family Planning & Reproductive Health Association (NFPRHA), Washington, DC
| | - Daryn Eikner
- National Family Planning & Reproductive Health Association (NFPRHA), Washington, DC
| | - Clare M Coleman
- National Family Planning & Reproductive Health Association (NFPRHA), Washington, DC
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Lowrie R, McConnachie A, Williamson AE, Kontopantelis E, Forrest M, Lannigan N, Mercer SW, Mair FS. Incentivised chronic disease management and the inverse equity hypothesis: findings from a longitudinal analysis of Scottish primary care practice-level data. BMC Med 2017; 15:77. [PMID: 28395660 PMCID: PMC5387284 DOI: 10.1186/s12916-017-0833-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 03/07/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The inverse equity hypothesis asserts that new health policies initially widen inequality, then attenuate inequalities over time. Since 2004, the UK's pay-for-performance scheme for chronic disease management (CDM) in primary care general practices (the Quality and Outcomes Framework) has permitted practices to except (exclude) patients from attending annual CDM reviews, without financial penalty. Informed dissent (ID) is one component of exception rates, applied to patients who have not attended due to refusal or non-response to invitations. 'Population achievement' describes the proportion receiving care, in relation to those eligible to receive it, including excepted patients. Examination of exception reporting (including ID) and population achievement enables the equity impact of the UK pay-for-performance contract to be assessed. We conducted a longitudinal analysis of practice-level rates and of predictors of ID, overall exceptions and population achievement for CDM to examine whether the inverse equity hypothesis holds true. METHODS We carried out a retrospective, longitudinal study using routine primary care data, analysed by multilevel logistic regression. Data were extracted from 793 practices (83% of Scottish general practices) serving 4.4 million patients across Scotland from 2010/2011 to 2012/2013, for 29 CDM indicators covering 11 incentivised diseases. This provided 68,991 observations, representing a total of 15 million opportunities for exception reporting. RESULTS Across all observations, the median overall exception reporting rate was 7.0% (7.04% in 2010-2011; 7.02% in 2011-2012 and 6.92% in 2012-2013). The median non-attendance rate due to ID was 0.9% (0.76% in 2010-2011; 0.88% in 2011-2012 and 0.96% in 2012-2013). Median population achievement was 83.5% (83.51% in 2010-2011; 83.41% in 2011-2012 and 83.63% in 2012-2013). The odds of ID reporting in 2012/2013 were 16.0% greater than in 2010/2011 (p < 0.001). Practices in Scotland's most deprived communities were twice as likely to report non-attendance due to ID (odds ratio 2.10, 95% confidence interval 1.83-2.40, p < 0.001) compared with those in the least deprived; rural practices reported lower levels of non-attendance due to ID. These predictors were also independently associated with overall exceptions. Rates of population achievement did not change over time, with higher levels (higher remuneration) associated with increased rates of overall and ID exception and more affluent practices. CONCLUSIONS Non-attendance for CDM due to ID has risen over time, and higher rates are seen in patients from practices located in disadvantaged areas. This suggests that CDM incentivisation does not conform to the inverse equity hypothesis, because inequalities are widening over time with lower uptake of anticipatory care health checks and CDM reviews noted among those most in need. Incentivised CDM needs to include incentives for engaging with the 'hard to reach' if inequalities in healthcare delivery are to be tackled.
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Affiliation(s)
- Richard Lowrie
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, Scotland G3 8SJ UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
| | - Andrea E. Williamson
- General Practice and Primary Care, School of Medicine, MVLS, University of Glasgow, Glasgow, Scotland UK
| | - Evangelos Kontopantelis
- The Farr Institute of Health Informatics Research, University of Manchester, Manchester, England UK
| | - Marie Forrest
- East Glasgow Health and Social Care Partnership, Paradise Health Centre, Glasgow, Scotland UK
| | - Norman Lannigan
- Pharmacy and Prescribing Support Unit, NHS Greater Glasgow and Clyde, Glasgow, Scotland G3 8SJ UK
| | - Stewart W. Mercer
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
| | - Frances S. Mair
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, Scotland UK
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Ju Kim S, Han KT, Kim SJ, Park EC. Pay-for-performance reduces healthcare spending and improves quality of care: Analysis of target and non-target obstetrics and gynecology surgeries. Int J Qual Health Care 2017; 29:222-227. [PMID: 28407094 DOI: 10.1093/intqhc/mzw159] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 04/11/2017] [Indexed: 01/15/2023] Open
Abstract
Objective In Korea, the Value Incentive Program (VIP) was first applied to selected clinical conditions in 2007 to evaluate the performance of medical institutes. We examined whether the condition-specific performance of the VIP resulted in measurable improvement in quality of care and in reduced medical costs. Design Population-based retrospective observational study. Setting We used two data set including the results of quality assessment and hospitalization data from National Health Claim data from 2011 to 2014. Participants Participants who were admitted to the hospital for obstetrics and gynecology were included. A total of 535 289 hospitalizations were included in our analysis. Methods We used a generalized estimating equation (GEE) model to identify associations between the quality assessment and length of stay (LOS). A GEE model based on a gamma distribution was used to evaluate medical cost. The Poisson regression analysis was used to evaluate readmission. Main Outcome Measures The outcome variables included LOS, medical costs and readmission within 30 days. Results Higher condition-specific performance by VIP participants was associated with shorter LOSs, decreases in medical cost, and lower within 30-day readmission rates for target and non-target surgeries. LOS and readmission within 30 days were different by change in quality assessment at each medical institute. Conclusions Our findings contribute to the body of evidence used by policy-makers for expansion and development of the VIP. The study revealed the positive effects of quality assessment on quality of care. To reduce the between-institute quality gap, alternative strategies are needed for medical institutes that had low performance.
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Affiliation(s)
- Seung Ju Kim
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Kyu-Tae Han
- Department of Public Health, Graduate School, Yonsei University, Seoul, Republic of Korea.,Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea
| | - Sun Jung Kim
- Department of Health Administration, Soonchunhyang University, Chungnam, Republic of Korea
| | - Eun-Cheol Park
- Institute of Health Services Research, Yonsei University, Seoul, Republic of Korea.,Department of Preventive Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
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31
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Results, Knowledge, and Attitudes Regarding an Incentive Compensation Plan in a Hospital-Based, Academic, Employed Physician Multispecialty Group. J Healthc Manag 2017; 62:120-133. [PMID: 28282335 DOI: 10.1097/jhm-d-17-00009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
EXECUTIVE SUMMARY Hospitals and healthcare systems are introducing incentive metrics into compensation plans that align with value-based payment methodologies. These incentive measures should be considered a practical application of the transition from volume to value and will likely replace traditional productivity-based compensation in the future. During the transition, there will be provider resistance and implementation challenges. This article examines a large multispecialty group's experience with a newly implemented incentive compensation plan including the structure of the plan, formulas for calculation of the payments, the mix of quality and productivity metrics, and metric threshold achievement. Three rounds of surveys with comments were collected to measure knowledge and attitudes regarding the plan. Lessons learned and specific recommendations for success are described. The participant's knowledge and attitudes regarding the plan are important considerations and affect morale and engagement. Significant provider dissatisfaction with the plan was found. Careful metric selection, design, and management are critical activities that will facilitate provider acceptance and support. Improvements in data collection and reporting will be needed to produce reliable metrics that can supplant traditional volume-based productivity measures.
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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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Miller BF, Ross KM, Davis MM, Melek SP, Kathol R, Gordon P. Payment reform in the patient-centered medical home: Enabling and sustaining integrated behavioral health care. AMERICAN PSYCHOLOGIST 2017; 72:55-68. [PMID: 28068138 PMCID: PMC7324070 DOI: 10.1037/a0040448] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
The patient-centered medical home (PCMH) is a promising framework for the redesign of primary care and more recently specialty care. As defined by the Agency for Healthcare Research and Quality, the PCMH framework has 5 attributes: comprehensive care, patient-centered care, coordinated care, accessible services, and quality and safety. Evidence increasingly demonstrates that for the PCMH to best achieve the Triple Aim (improved outcomes, decreased cost, and enhanced patient experience), treatment for behavioral health (including mental health, substance use, and life stressors) must be integrated as a central tenet. However, challenges to implementing the PCMH framework are compounded for real-world practitioners because payment reform rarely happens concurrently. Nowhere is this more evident than in attempts to integrate behavioral health clinicians into primary care. As behavioral health clinicians find opportunities to work in integrated settings, a comprehensive understanding of payment models is integral to the dialogue. This article describes alternatives to the traditional fee for service (FFS) model, including modified FFS, pay for performance, bundled payments, and global payments (i.e., capitation). We suggest that global payment structures provide the best fit to enable and sustain integrated behavioral health clinicians in ways that align with the Triple Aim. Finally, we present recommendations that offer specific, actionable steps to achieve payment reform, complement PCMH, and support integration efforts through policy. (PsycINFO Database Record
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Affiliation(s)
- Benjamin F Miller
- Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine
| | - Kaile M Ross
- Eugene S. Farley, Jr. Health Policy Center, University of Colorado School of Medicine
| | - Melinda M Davis
- Department of Family Medicine, Oregon Health and Sciences University
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Abstract
The use of financial incentives to improve quality in health care has become widespread. Yet evidence on the effectiveness of incentives suggests that they have generally had limited impact on the value of care and have not led to better patient outcomes. Lessons from social psychology and behavioral economics indicate that incentive programs in health care have not been effectively designed to achieve their intended impact. In the United States, Medicare's Hospital Readmission Reduction Program and Hospital Value-Based Purchasing Program, created under the Affordable Care Act (ACA), provide evidence on how variations in the design of incentive programs correspond with differences in effect. As financial incentives continue to be used as a tool to increase the value and quality of health care, improving the design of programs will be crucial to ensure their success.
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Affiliation(s)
- Tim Doran
- Department of Health Sciences, University of York, Heslington, York YO10 5DD, United Kingdom;
| | - Kristin A Maurer
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan 48109; ,
| | - Andrew M Ryan
- Department of Health Management and Policy, School of Public Health, University of Michigan, Ann Arbor, Michigan 48109; ,
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35
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O'Donnell A, Haighton C, Chappel D, Shevills C, Kaner E. Impact of financial incentives on alcohol intervention delivery in primary care: a mixed-methods study. BMC FAMILY PRACTICE 2016; 17:165. [PMID: 27887577 PMCID: PMC5124277 DOI: 10.1186/s12875-016-0561-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/23/2016] [Accepted: 11/14/2016] [Indexed: 11/10/2022]
Abstract
BACKGROUND Local and national financial incentives were introduced in England between 2008 and 2015 to encourage screening and brief alcohol intervention delivery in primary care. We used routine Read Code data and interviews with General Practitioners (GPs) to assess their impact. METHODS A sequential explanatory mixed-methods study was conducted in 16 general practices representing 106,700 patients and 99 GPs across two areas in Northern England. Data were extracted on screening and brief alcohol intervention delivery for 2010-11 and rates were calculated by practice incentive status. Semi-structured interviews with 14 GPs explored which factors influence intervention delivery and recording in routine consultations. RESULTS Screening and brief alcohol intervention rates were higher in financially incentivised compared to non-incentivised practices. However absolute rates were low across all practices. Rates of short screening test administration ranged from 0.05% (95% CI: 0.03-0.08) in non-incentivised practices to 3.92% (95% CI: 3.70-4.14) in nationally incentivised practices. For the full AUDIT, rates were also highest in nationally incentivised practices (3.68%, 95% CI: 3.47-3.90) and lowest in non-incentivised practices (0.17%, 95% CI: 0.13-0.22). Delivery of alcohol interventions was highest in practices signed up to the national incentive scheme (9.23%, 95% CI: 8.91-9.57) and lowest in non-incentivised practices (4.73%, 95% CI: 4.50-4.96). GP Interviews highlighted a range of influences on alcohol intervention delivery and subsequent recording including: the hierarchy of different financial incentive schemes; mixed belief in the efficacy of alcohol interventions; the difficulty of codifying complex conditions; and GPs' beliefs about patient-centred practice. CONCLUSIONS Financial incentives have had some success in encouraging screening and brief alcohol interventions in England, but levels of recorded activity remain low. To improve performance, future policies must prioritise alcohol prevention work within the quality and outcomes framework, and address the values, attitudes and beliefs that shape how GPs' provide care.
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Affiliation(s)
- Amy O'Donnell
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.
| | - Catherine Haighton
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK.,Department of Public Health and Wellbeing, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | | | | | - Eileen Kaner
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
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36
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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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Greene J, Sacks RM, Hibbard JH, Overton V. How much do clinicians support patient self-management? The development of a measure to assess clinician self-management support. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2016; 5:34-39. [PMID: 27594306 DOI: 10.1016/j.hjdsi.2016.05.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 02/22/2016] [Accepted: 05/12/2016] [Indexed: 11/15/2022]
Abstract
BACKGROUND Primary care provider (PCP) support of patient self-management may be important mechanism to improving patient health outcomes. In this paper we develop a PCP-reported measure of clinician strategies for supporting patient self-management, and we psychometrically test and validate the measure. METHODS We developed survey items based upon effective self-management support strategies identified in a prior mixed methods study. We fielded a survey in the fall of 2014 with 139 Fairview Health Services PCPs, and conducted exploratory factor analysis and Cronbach's Alpha to test for scale reliability. To validate the measure, we examined the Self-Management Support (SMS) scale's relationship to survey items on self-management support, as well as clinicians' patient panel rates of smoking cessation and weight loss. RESULTS Nine survey items clustered reliably to create a single factor (Cronbach's Alpha=0.73). SMS scores ranged from 2.1 to 4.9. The SMS was related to each of the validation variables. PCPs who reported spending 60% percent or more of their time counseling, educating, and coaching patients had a mean SMS score of 4.0, while those who reported spending less than 30% of their time doing so had mean SMS scores 15% lower. PCPs' SMS scores exhibited significant but modest associations with their patients' smoking cessation and weight loss (among obese patients) (r=0.21 and r=0.13 respectively). CONCLUSIONS This study develops and tests a promising measure of PCPs' strategies to support patient self-management. It highlights variation across PCPs. Future work should examine whether increasing scores of PCPs low on the SMS improves chronic care quality outcomes.
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Affiliation(s)
- Jessica Greene
- George Washington University, 2030 M Street, Suite 300, Washington, DC 20036, United States.
| | - Rebecca M Sacks
- George Washington University, 2030 M Street, Suite 300, Washington, DC 20036, United States
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Park S, Han E. Do Physicians Change Prescription Practice in Response to Financial Incentives? INTERNATIONAL JOURNAL OF HEALTH SERVICES 2016; 46:531-46. [PMID: 27193920 DOI: 10.1177/0020731416649846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We assessed the impact on physician prescription behaviors of an outpatient prescription incentive program providing financial rewards to primary care physicians for saving prescription costs in South Korea. A 10% sample of clinics (N = 1,625) was randomly selected from all clinics in the National Health Insurance claims database for the years 2009-2012, and all claims with the primary diagnosis of peptic ulcer or gastro-esophageal reflux diseases were extracted from those clinics' data. A clinic-level random-effects model was used. After the program, clinics in general medicine showed a lower prescription rate (by 0.8 percentage points), lower number of medicines prescribed (by 0.02), lower prescription duration (by 0.15 days), and lower drug expenditure per claim (by 740 won). Small clinics on the <25th percentile of a regional sum of monthly drug expenditure had shorter prescription duration (by 0.76 days), while large clinics on the ≥75th percentile and clinics in group practice had a higher prescription rate (by 1.5 and 2.5 percentage points, respectively) and a higher number of medicines prescribed (by 0.03 for group practice only) after the program. The outpatient prescription incentive program worked as intended only in certain subgroup clinics for the target medicines.
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Affiliation(s)
- Sylvia Park
- Korea Institute for Health and Social Affairs, Sejong City, South Korea
| | - Euna Han
- College of Pharmacy, Yonsei University, South Korea
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39
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Augustine S. Does Money Really Talk? A Resident-Driven Pay-for-Performance Pilot. J Grad Med Educ 2016; 8:277-8. [PMID: 27168906 PMCID: PMC4857521 DOI: 10.4300/jgme-d-16-00105.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Affiliation(s)
- Sarah Augustine
- Corresponding author: Sarah Augustine, MD, Case Western Reserve University School of Medicine, 2109 Adelbert Road, Cleveland, OH 44106,
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40
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Portrait FRM, van der Galiën O, Van den Berg B. Measuring Healthcare Providers' Performances Within Managed Competition Using Multidimensional Quality and Cost Indicators. HEALTH ECONOMICS 2016; 25:408-423. [PMID: 25702821 DOI: 10.1002/hec.3158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Revised: 10/20/2014] [Accepted: 01/14/2015] [Indexed: 06/04/2023]
Abstract
BACKGROUND AND OBJECTIVES The Dutch healthcare system is in transition towards managed competition. In theory, a system of managed competition involves incentives for quality and efficiency of provided care. This is mainly because health insurers contract on behalf of their clients with healthcare providers on, potentially, quality and costs. The paper develops a strategy to comprehensively analyse available multidimensional data on quality and costs to assess and report on the relative performance of healthcare providers within managed competition. DATA AND METHODS We had access to individual information on 2409 clients of 19 Dutch diabetes care groups on a broad range of (outcome and process related) quality and cost indicators. We carried out a cost-consequences analysis and corrected for differences in case mix to reduce incentives for risk selection by healthcare providers. RESULTS AND CONCLUSION There is substantial heterogeneity between diabetes care groups' performances as measured using multidimensional indicators on quality and costs. Better quality diabetes care can be achieved with lower or higher costs. Routine monitoring using multidimensional data on quality and costs merged at the individual level would allow a systematic and comprehensive analysis of healthcare providers' performances within managed competition.
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Greene J, Hibbard JH, Alvarez C, Overton V. Supporting Patient Behavior Change: Approaches Used by Primary Care Clinicians Whose Patients Have an Increase in Activation Levels. Ann Fam Med 2016; 14:148-54. [PMID: 26951590 PMCID: PMC4781518 DOI: 10.1370/afm.1904] [Citation(s) in RCA: 69] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
PURPOSE We aimed to identify the strategies used to support patient behavior change by clinicians whose patients had an increase in patient activation. METHODS This mixed methods study was conducted in collaboration with Fairview Health Services, a Pioneer Accountable Care Organization. We aggregated data on the change in patient activation measure (PAM) score for 7,144 patients to the primary care clinician level. We conducted in-depth interviews with 10 clinicians whose patients' score increases were among the highest and 10 whose patients' score changes were among the lowest. Transcripts of the interviews were analyzed to identify key strategies that differentiated the clinicians whose patients had top PAM change scores. RESULTS Clinicians whose patients had relatively large activation increases reported using 5 key strategies to support patient behavior change (mean = 3.9 strategies): emphasizing patient ownership; partnering with patients; identifying small steps; scheduling frequent follow-up visits to cheer successes, problem solve, or both; and showing caring and concern for patients. Clinicians whose patients had lesser change in activation were far less likely to describe using these approaches (mean = 1.3 strategies). Most clinicians, regardless of group, reported developing their own approach to support patient behavior change. Those whose patients showed high activation change reported spending more time with patients on counseling and education than did those whose patients showed less improvement in activation. CONCLUSIONS Clinicians vary in the strategies they use to promote behavior change and in the time spent with patients on such activities. The 5 key strategies used by clinicians with high patient activation change are promising approaches to supporting patient behavior change that should be tested in a larger sample of clinicians to validate their effectiveness.
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Affiliation(s)
- Jessica Greene
- School of Nursing, George Washington University, Washington, DC
| | | | - Carmen Alvarez
- School of Nursing, Department of Community-Public Health, Johns Hopkins University, Baltimore, Maryland
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Nothacker M, Stokes T, Shaw B, Lindsay P, Sipilä R, Follmann M, Kopp I. Reporting standards for guideline-based performance measures. Implement Sci 2016; 11:6. [PMID: 26772173 PMCID: PMC4714427 DOI: 10.1186/s13012-015-0369-z] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2015] [Accepted: 12/30/2015] [Indexed: 11/10/2022] Open
Abstract
Background The Guidelines International Network (G-I-N) aims to promote high quality clinical guideline development and implementation. Guideline-based performance measures are a key implementation tool and are widely used internationally for quality improvement, quality assurance, and pay for performance in health care. There is, however, no international consensus on best methods for guideline-based performance measures. In order to address this issue, the G-I-N Performance Measures Working Group aimed to develop a set of consensus-based reporting standards for guideline-based performance measure development and re-evaluation. Methods Methodology publications on guideline-based performance measures were identified from a systematic literature review and analyzed. Core criteria for the development and evaluation process of guideline-based performance measures were determined and refined into draft standards with an associated rationale and description of the evidence base. In a two-round Delphi-process, the group members appraised and approved the draft standards. After the first round, the group met to discuss comments and revised the drafts accordingly. Results Twenty-one methodology publications were reviewed. The group reached strong consensus on nine reporting standards concerning: (1) selection of clinical guidelines, (2) extraction of clinical guideline recommendations, (3) description of the measure development process, (4) measure appraisal, (5) measure specification, (6) description of the intended use of the measure, (7) measure testing/validating, (8) measure review/re-evaluation, and (9) composition of the measure development panel. Conclusions These proposed international reporting standards address core components of guideline-based performance measure development and re-evaluation. They are intended to contribute to international reporting harmonization and improvement of methods for performance measures. Further research is required regarding validity, acceptability, and practicality. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0369-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften-Institut für Medizinisches Wissensmanagement (AWMF-IMWI), Philipps-Universität Marburg, Karl-von-Frisch-Str.1, Marburg, 35043, Germany.
| | - Tim Stokes
- Department of General Practice and Rural Health, Dunedin School of Medicine, University of Otago, Dunedin, New Zealand
| | - Beth Shaw
- National Institute for Health and Care Excellence (NICE), Manchester, UK
| | | | - Raija Sipilä
- The Finnish Medical Society Duodecim, Current Care Guidelines, Helsinki, Finland
| | | | - Ina Kopp
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften-Institut für Medizinisches Wissensmanagement (AWMF-IMWI), Philipps-Universität Marburg, Karl-von-Frisch-Str.1, Marburg, 35043, Germany
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43
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Roland M. Should doctors be able to exclude patients from pay-for-performance schemes? BMJ Qual Saf 2015; 25:653-6. [PMID: 26717988 DOI: 10.1136/bmjqs-2015-005003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/26/2015] [Indexed: 12/25/2022]
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Bardach NS, Lyndon A, Asteria-Peñaloza R, Goldman LE, Lin GA, Dudley RA. From the closest observers of patient care: a thematic analysis of online narrative reviews of hospitals. BMJ Qual Saf 2015; 25:889-897. [PMID: 26677215 DOI: 10.1136/bmjqs-2015-004515] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2015] [Revised: 10/31/2015] [Accepted: 11/14/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Patient-centred care has become a priority in many countries. It is unknown whether current tools capture aspects of care patients and their surrogates consider important. We investigated whether online narrative reviews from patients and surrogates reflect domains in the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) and we described additional potential domains. DESIGN We used thematic analysis to assess online narrative reviews for reference to HCAHPS domains and salient non-HCAHPS domains and compared results by reviewer type (patient vs surrogate). SETTING We identified hospitals for review from the American Hospital Association database using a stratified random sampling approach. This approach ensured inclusion of reviews of a diverse set of hospitals. We searched online in February 2013 for narrative reviews from any source for each hospital. PARTICIPANTS We included up to two narrative reviews for each hospital. EXCLUSIONS Outpatient or emergency department reviews, reviews from self-identified hospital employees, or reviews of <10 words. RESULTS 50.0% (n=122) of reviews (N=244) were from patients and 38.1% (n=93) from friends or family members. Only 57.0% (n=139) of reviews mentioned any HCAHPS domain. Additional salient domains were: Financing, including unexpected out-of-pocket costs and difficult interactions with billing departments; system-centred care; and perceptions of safety. These domains were mentioned in 51.2% (n=125) of reviews. Friends and family members commented on perceptions of safety more frequently than patients. CONCLUSIONS A substantial proportion of consumer reviews do not mention HCAHPS domains. Surrogates appear to observe care differently than patients, particularly around safety.
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Affiliation(s)
- Naomi S Bardach
- Department of Pediatrics, University of California San Francisco, San Francisco, California, USA.,Philip R. Lee Institute for Health Policy, University of California San Francisco, San Francisco, USA
| | - Audrey Lyndon
- Family Health Care Nursing, University of California San Francisco, San Francisco, California, USA
| | - Renée Asteria-Peñaloza
- Philip R. Lee Institute for Health Policy, University of California San Francisco, San Francisco, USA
| | - L Elizabeth Goldman
- Department of Medicine, University of California San Francisco, San Francisco, USA
| | - Grace A Lin
- Philip R. Lee Institute for Health Policy, University of California San Francisco, San Francisco, USA.,Department of Medicine, University of California San Francisco, San Francisco, USA
| | - R Adams Dudley
- Philip R. Lee Institute for Health Policy, University of California San Francisco, San Francisco, USA.,Department of Medicine, University of California San Francisco, San Francisco, USA
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Roland M, Dudley RA. How Financial and Reputational Incentives Can Be Used to Improve Medical Care. Health Serv Res 2015; 50 Suppl 2:2090-115. [PMID: 26573887 PMCID: PMC5338201 DOI: 10.1111/1475-6773.12419] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVES Narrative review of the impact of pay-for-performance (P4P) and public reporting (PR) on health care outcomes, including spillover effects and impact on disparities. PRINCIPAL FINDINGS The impact of P4P and PR is dependent on the underlying payment system (fee-for-service, salary, capitation) into which these schemes are introduced. Both have the potential to improve care, but they can also have substantial unintended consequences. Evidence from the behavioral economics literature suggests that individual physicians will vary in how they respond to incentives. We also discuss issues to be considered when including patient-reported outcome measures (PROMs) or patient-reported experience measures into P4P and PR schemes. CONCLUSION We provide guidance to payers and policy makers on the design of P4P and PR programs so as to maximize their benefits and minimize their unintended consequences. These include involving clinicians in the design of the program, taking into account the payment system into which new incentives are introduced, designing the structure of reward programs to maximize the likelihood of intended outcomes and minimize the likelihood of unintended consequences, designing schemes that minimize the risk of increasing disparities, providing stability of incentives over some years, and including outcomes that are relevant to patients' priorities. In addition, because of the limitations of PR and P4P as effective interventions in their own right, it is important that they are combined with other policies and interventions intended to improve quality to maximize their likely impact.
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Affiliation(s)
- Martin Roland
- Department of Public Health and Primary Care, Institute of Public Health, University of Cambridge, Robinson Way, Cambridge CB2 0SR, UK
| | - R Adams Dudley
- Center for Healthcare Value, Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA
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Physical health indicators in major mental illness: analysis of QOF data across UK general practice. Br J Gen Pract 2015; 64:e649-56. [PMID: 25267051 DOI: 10.3399/bjgp14x681829] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The Quality and Outcomes Framework (QOF) has specific targets for body mass index (BMI) and blood pressure recording in major mental illness (MMI), diabetes, and chronic kidney disease (CKD). Although aspects of MMI (schizophrenia, bipolar disorder, and related psychoses) are incentivised, barriers to care may occur. AIM To compare payment, population achievement, and exception rates for blood pressure and BMI recording in MMI relative to diabetes and CKD across the UK. DESIGN AND SETTING Analysis of 2012/2013 QOF data from 9731 UK general practices 2 years after the introduction of the mental health, BMI, and blood pressure QOF indicators. METHOD Payment, exception, and population achievement rates for the MMI and CKD blood pressure indicators and the MMI and diabetes BMI indicators were calculated and compared. RESULTS UK payment and population achievement rates for BMI recording for MMI were significantly lower than for diabetes (payment: 92.7% versus 95.5% and population achievement: 84.0% versus 92.5%, P<0.001) and exception rates were higher (8.1% versus 2.0%, P<0.001). For blood pressure recording, UK payment and population achievement rates were significantly lower for MMI than for CKD (94.1% versus 97.8% and 87.0% versus 97.1%, P<0.001), while exception rate was higher (6.5% versus 0.0%, P<0.001). This was observed for all countries. Compared with England, Northern Ireland had higher population achievement rates for both mental health indicators, whereas Scotland and Wales had lower rates. There were no cross-jurisdiction differences for CKD and diabetes. CONCLUSION Differences in payment, exception, and population achievement rates for blood pressure and BMI recording for MMI relative to CKD and diabetes were observed across the UK. These findings suggest potential inequalities in the monitoring of physical health in MMI within the UK primary care system.
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Abstract
CONTEXT In its fee-for-service funding model for primary care, British Columbia, Canada, introduced incentive payments to general practitioners as pay for performance for providing enhanced, guidelines-based care to patients with chronic conditions. Evaluation of the program was conducted at the health care system level. OBJECTIVE To examine the impact of the incentive payments on annual health care costs and hospital utilization patterns in British Columbia. DESIGN The study used Ministry of Health administrative data for Fiscal Year 2010-2011 for patients with diabetes, congestive heart failure, chronic obstructive pulmonary disease, and/or hypertension. In each disease group, cost and utilization were compared across patients who did, and did not, receive incentive-based care. MAIN OUTCOME MEASURES Health care costs (eg, primary care, hospital) and utilization measures (eg, hospital days, readmissions). RESULTS After controlling for patients' age, sex, service needs level, and continuity of care (defined as attachment to a general practice), the incentives reduced the net annual health care costs, in Canadian dollars, for patients with hypertension (by approximately Can$308 per patient), chronic obstructive pulmonary disease (by Can$496), and congestive heart failure (by Can$96), but not diabetes (incentives cost about Can$148 more per patient). The incentives were also associated with fewer hospital days, fewer admissions and readmissions, and shorter lengths of hospital stays for all 4 groups. CONCLUSION Although the available literature on pay for performance shows mixed results, we showed that the funding model used in British Columbia using incentive payments for primary care might reduce health care costs and hospital utilization.
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Affiliation(s)
- Marcus J Hollander
- The President of Hollander Analytical Services, Ltd, in Victoria, British Columbia, Canada.
| | - Helena Kadlec
- The Senior Scientist for Hollander Analytical Services, Ltd, in Victoria, British Columbia, Canada.
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Leaders’ experiences and perceptions implementing activity-based funding and pay-for-performance hospital funding models: A systematic review. Health Policy 2015; 119:1096-110. [DOI: 10.1016/j.healthpol.2015.05.003] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2014] [Revised: 04/10/2015] [Accepted: 05/04/2015] [Indexed: 12/19/2022]
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Abstract
BACKGROUND Pay for performance was implemented in 2009 in France. The system was optional at first and then became widespread. Since 2012, it has been standard for most GPs. Several studies have attempted to investigate its efficiency and the GP's opinion of the system, but few studies have yet to examine the patient's view. AIM To gain an understanding of the views of French family practice patients about pay for performance. DESIGN AND SETTING Forty patients were interviewed between March and July 2013 in the Île-de-France region, of France. METHOD A qualitative study using semi-structured individual interviews, in primary care. RESULTS Most of the patients did not know what pay for performance was and stated that they had not noticed any change in care since the system began. Some patients noted the possible benefits in the quality of care, such as an improvement in follow-up and prevention, better information provided by the GP, and a decrease in the volume of prescriptions and therefore health costs. Other patients were concerned about potential downsides, such as an overprescription of unnecessary medical treatments, an increase in health costs, patient selection, and standardised consultations that do not necessarily take into account the patient's individual concerns. CONCLUSION Since implementation of pay for performance, patients had not noticed any modification in their medical care. They could understand the need for change in the remuneration policy and expressed their agreement about performance-based remuneration if, and only if, it is not the cause of depersonalised health care.
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Hsieh HM, Tsai SL, Mau LW, Chiu HC. Effects of Changes in Diabetes Pay-for-Performance Incentive Designs on Patient Risk Selection. Health Serv Res 2015; 51:667-86. [PMID: 26152649 DOI: 10.1111/1475-6773.12338] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE Taiwan's National Health Insurance (NHI) Program implemented a Diabetes Pay-for-Performance Program (P4P) based on process-of-care measures in 2001. In late 2006, that P4P program was reformed to also include achievement of intermediate health outcomes. This study examined how the change in design affected patient risk selection. DESIGNS/STUDY POPULATIONS Study populations were identified from a 2002 to 2003 period (Phase 1) and a 2007 to 2008 period (Phase 2), spanning pre- and postimplementation of reforms in the P4P incentive design. Phase 1 had 74,529 newly enrolled P4P patients and 215,572 non-P4P patients, and Phase 2 had 76,901 newly enrolled P4P patients and 299,573 non-P4P patients. Logistic regression models were used to estimate the effect of changes in design on P4P patient selection. PRINCIPAL FINDINGS Patients with greater disease severity and comorbidity were more likely to be excluded from the P4P program in both phases. Furthermore, the additional financial incentive for patients' intermediate outcomes moderately worsened patient risk selection. CONCLUSIONS Policy makers need to carefully monitor the care of the diabetes patients with more severe and complex disease statuses after the changes of P4P financial incentive design.
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Affiliation(s)
- Hui-Min Hsieh
- Department of Public Health, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Shu-Ling Tsai
- National Health Insurance Administration, Ministry of Health and Welfare, Taipei, Taiwan
| | - Lih-Wen Mau
- Patient & Health Professional Services, National Marrow Donor Organization, Edina, MN
| | - Herng-Chia Chiu
- Department of Healthcare Administration and Medical Informatics, Kaohsiung Medical University, Kaohsiung, Taiwan
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