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Ishida R, Koga K, Ohbe H, Izumi G, Matsui H, Yasunaga H, Osuga Y. Impact of government-issued financial incentive to medical facilities on management of secondary dysmenorrhea. J Obstet Gynaecol Res 2024; 50:1208-1215. [PMID: 38597093 DOI: 10.1111/jog.15946] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 03/31/2024] [Indexed: 04/11/2024]
Abstract
AIM In April 2020, the Japanese government introduced a Specific Medical Fee for managing secondary dysmenorrhea (SD). This initiative provided financial incentives to medical facilities that provide appropriate management of SD with hormonal therapies. We aimed to assess how this policy affects the management processes and outcomes of patients with SD. METHODS Using a large Japanese administrative claims database, we identified outpatient visits of patients diagnosed with SD from April 2018 to March 2022. We used an interrupted time-series analysis and defined before April 2020 as the pre-introduction period and after April 2020 as the post-introduction period. Outcomes were the monthly proportions of outpatient visits due to SD and hormonal therapy among women in the database and the proportions of outpatient visits for hormonal therapy and continuous outpatient visits among patients with SD. RESULTS We identified 815 477 outpatient visits of patients diagnosed with SD during the pre-introduction period and 920 183 outpatient visits during the post-introduction period. There were significant upward slope changes after the introduction of financial incentives in the outpatient visits due to SD (+0.29% yearly; 95% confidence interval, +0.20% to +0.38%) and hormonal therapies (+0.038% yearly; 95% confidence interval, +0.030% to +0.045%) among the women in the database. Similarly, a significant level change was observed after the introduction of continuous outpatient visits among patients with SD (+2.68% monthly; 95% confidence interval, +0.87% to +4.49%). CONCLUSIONS Government-issued financial incentives were associated with an increase in the number of patients diagnosed with SD, hormonal therapies, and continuous outpatient visits.
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Affiliation(s)
- Risa Ishida
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kaori Koga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
- Department of Reproductive Medicine, Chiba University, Chiba, Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Gentaro Izumi
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Yutaka Osuga
- Department of Obstetrics and Gynecology, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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Staples JA, Yu Y, Khan M, Naik H, Liu G, Brubacher JR, Karimuddin A, Sutherland JM. Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: A Propensity Score Weighted Cohort Study. Am J Med 2024:S0002-9343(24)00278-X. [PMID: 38750712 DOI: 10.1016/j.amjmed.2024.04.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 04/15/2024] [Accepted: 04/28/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Unplanned hospital readmissions are associated with adverse patient outcomes and substantial healthcare costs. It remains unknown whether physician financial incentives for enhanced discharge planning can reduce readmission risk. METHODS In 2012, policymakers in British Columbia, Canada, introduced a $75 fee-for-service physician payment to incentivize enhanced discharge planning (the "G78717" fee code). We used population-based administrative health data to compare outcomes among G78717-exposed and G78717-unexposed patients. We identified all nonelective hospitalizations potentially eligible for the incentive over a 5-year study interval. We examined the composite risk of unplanned readmission or death and total direct healthcare costs accrued within 30 days of discharge. Propensity score overlap weights and adjustment were used to account for differences between exposed and unexposed patients. RESULTS A total of 5262 of 24,787 G78717-exposed and 28,096 of 136,541 unexposed patients experienced subsequent unplanned readmission or death, suggesting exposure to the G78717 incentive did not reduce the risk of adverse outcomes after discharge (crude percent, 21.1% vs 20.6%; adjusted odds ratio, 0.97; 95% CI, 0.93-1.01; P = .23). Mean direct healthcare costs within 30 days of discharge were $3082 and $2993, respectively (adjusted cost ratio, 1.00; 95% CI, 0.95-1.05; P = .93). CONCLUSIONS A physician financial incentive that encouraged enhanced hospital discharge planning did not reduced the risk of readmission or death, and did not significantly decrease direct healthcare costs. Policymakers should consider the baseline prevalence and effectiveness of enhanced discharge planning, the magnitude and design of financial incentives, and whether auditing of incentivized activities is required when implementing similar incentives elsewhere. TRIAL REGISTRATION ClinicalTrials.gov ID, NCT03256734.
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Affiliation(s)
- John A Staples
- Department of Medicine, University of British Columbia, Vancouver, Canada; Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, Canada; Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada.
| | - Ying Yu
- Department of Medicine, University of British Columbia, Vancouver, Canada.
| | - Mayesha Khan
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Hiten Naik
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Guiping Liu
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Ahmer Karimuddin
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Jason M Sutherland
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada; Department of Emergency Medicine, University of British Columbia, Vancouver, Canada.
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Naik H, Murray TM, Khan M, Daly-Grafstein D, Liu G, Kassen BO, Onrot J, Sutherland JM, Staples JA. Population-Based Trends in Complexity of Hospital Inpatients. JAMA Intern Med 2024; 184:183-192. [PMID: 38190179 PMCID: PMC10775081 DOI: 10.1001/jamainternmed.2023.7410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2023] [Accepted: 11/11/2023] [Indexed: 01/09/2024]
Abstract
Importance Clinical experience suggests that hospital inpatients have become more complex over time, but few studies have evaluated this impression. Objective To assess whether there has been an increase in measures of hospital inpatient complexity over a 15-year period. Design, Setting and Participants This cohort study used population-based administrative health data from nonelective hospitalizations from April 1, 2002, to January 31, 2017, to describe trends in the complexity of inpatients in British Columbia, Canada. Hospitalizations were included for individuals 18 years and older and for which the most responsible diagnosis did not correspond to pregnancy, childbirth, the puerperal period, or the perinatal period. Data analysis was performed from July to November 2023. Exposure The passage of time (15-year study interval). Main Outcomes and Measures Measures of complexity included patient characteristics at the time of admission (eg, advanced age, multimorbidity, polypharmacy, recent hospitalization), features of the index hospitalization (eg, admission via the emergency department, multiple acute medical problems, use of intensive care, prolonged length of stay, in-hospital adverse events, in-hospital death), and 30-day outcomes after hospital discharge (eg, unplanned readmission, all-cause mortality). Logistic regression was used to estimate the relative change in each measure of complexity over the entire 15-year study interval. Results The final study cohort included 3 367 463 nonelective acute care hospital admissions occurring among 1 272 444 unique individuals (median [IQR] age, 66 [48-79] years; 49.1% female and 50.8% male individuals). Relative to the beginning of the study interval, inpatients at the end of the study interval were more likely to have been admitted via the emergency department (odds ratio [OR], 2.74; 95% CI, 2.71-2.77), to have multimorbidity (OR, 1.50; 95% CI, 1.47-1.53) and polypharmacy (OR, 1.82; 95% CI, 1.78-1.85) at presentation, to receive treatment for 5 or more acute medical issues (OR, 2.06; 95% CI, 2.02-2.09), and to experience an in-hospital adverse event (OR, 1.20; 95% CI, 1.19-1.22). The likelihood of an intensive care unit stay and of in-hospital death declined over the study interval (OR, 0.96; 95% CI, 0.95-0.97, and OR, 0.81; 95% CI, 0.80-0.83, respectively), but the risks of unplanned readmission and death in the 30 days after discharge increased (OR, 1.14; 95% CI, 1.12-1.16, and OR, 1.28; 95% CI, 1.25-1.31, respectively). Conclusions and Relevance By most measures, hospital inpatients have become more complex over time. Health system planning should account for these trends.
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Affiliation(s)
- Hiten Naik
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Tyler M. Murray
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Mayesha Khan
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Daniel Daly-Grafstein
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Department of Statistics, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Guiping Liu
- Center for Health Services and Policy Research (CHSPR), School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Barry O. Kassen
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jake Onrot
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Jason M. Sutherland
- Center for Health Services and Policy Research (CHSPR), School of Population and Public Health, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Advancing Health Outcomes, Vancouver, British Columbia, Canada
| | - John A. Staples
- Department of Medicine, The University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, British Columbia, Canada
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Benipal H, Demers C, Cerasuolo JO, Perez R, You JJ, Amin F, Keshavjee K, Lee DS. Association of a Heart Failure Management Incentive in Primary Care With Clinical Outcomes: A Retrospective Cohort Study. J Am Heart Assoc 2024; 13:e031498. [PMID: 38156519 PMCID: PMC10863798 DOI: 10.1161/jaha.123.031498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 08/23/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND We aim to examine the association between primary care physicians' billing of Q050A, a pay-for-performance heart failure (HF) management incentive fee code, and the composite outcome of mortality, hospitalization, and emergency department visits. METHODS AND RESULTS This population-based cohort study linked administrative health databases in Ontario, Canada, for patients with HF aged >66 years between January 1, 2008, and March 31, 2020. Cases were patients with HF who had a Q050A fee code billed. Cases and controls were matched 1:1 on age, sex, patient status on being rostered to a primary care physician, cardiologist, or internist visit in the 6 months before study enrollment, Johns Hopkins Adjusted Clinical Group resource use bands, days between HF diagnosis and study enrollment (±2 years), and the logit of the propensity score. A Cox proportional hazards model assessed the association of Q050A with the outcome. A total of 59 664 cases had a Q050A billed, whereas 244 883 patients did not. Before matching, patients who had a Q050A billed were more likely to be men (52% versus 49%), were rostered to a primary care physician (100% versus 96%), had a higher Charlson Comorbidity Index, and had higher health care costs. The mean follow-up was 481 days for cases and 530 days for controls. The composite outcome (hazard ratio, 1.11 [95% CI, 1.09-1.12]) was significantly higher for cases than controls. CONCLUSIONS The Q050A incentive improved financial compensation for primary care physicians managing patients with HF but was not associated with improvements in the outcome. Research on promoting evidence-based HF management is warranted.
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Affiliation(s)
- Harsukh Benipal
- Temerty Faculty of MedicineUniversity of TorontoToronto, OntarioCanada
| | - Catherine Demers
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
| | - Joshua O. Cerasuolo
- Department of Health Research Methods, Evidence and ImpactMcMaster UniversityHamiltonOntarioCanada
- Institute of Clinical Evaluative SciencesTorontoOntarioCanada
| | - Richard Perez
- Institute of Clinical Evaluative SciencesTorontoOntarioCanada
| | - John J. You
- Division of General Internal and Hospitalist MedicineCredit Valley Hospital, Trillium Health PartnersMississaugaOntarioCanada
| | - Faizan Amin
- Department of MedicineMcMaster UniversityHamiltonOntarioCanada
| | - Karim Keshavjee
- Institute of Health Policy, Management and EvaluationUniversity of TorontoToronto, OntarioCanada
- InfoClin IncTorontoOntarioCanada
| | - Douglas S. Lee
- Temerty Faculty of MedicineUniversity of TorontoToronto, OntarioCanada
- Institute of Clinical Evaluative SciencesTorontoOntarioCanada
- Institute of Health Policy, Management and EvaluationUniversity of TorontoToronto, OntarioCanada
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Lavergne R, Peterson S, Rudoler D, Scott I, Mccracken R, Mitra G, Katz A. Productivity Decline or Administrative Avalanche? Examining Factors That Shape Changing Workloads in Primary Care. Healthc Policy 2023; 19:114-129. [PMID: 37695712 PMCID: PMC10519339 DOI: 10.12927/hcpol.2023.27152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/13/2023] Open
Abstract
Background In Canada, family physicians (FPs) per capita have increased but so have access challenges. We explored changes in population characteristics, service delivery and FP practice that may help understand these trends. Methods We used linked administrative data in British Columbia to describe changes in patient ages and comorbidities, hospitalizations and receipt of services that may require FP coordination, review and/or follow-up: prescriptions dispensed, laboratory tests, diagnostic imaging (radiology and ultrasound), specialist visits and emergency department visits. We estimate the number of FPs delivering community-based comprehensive care and report changes in service volume per community-based FP visit. Results Between 1999/2000 and 2017/2018, people experienced fewer days in hospital, but the number of treated comorbidities, day surgeries and other services requiring FP coordination increased over and above the expected levels attributed to population aging. While the total number of FPs per capita have increased, numbers in community-based care have not and visits per physician have fallen. Increases in services that may involve FP coordination per community-based FP visit ranged from 32.2% for diagnostic radiology to 122.1% for lab tests. Conclusion Findings suggest substantially increased coordination workload per FP visit. Ongoing impacts of population aging and changing service delivery on primary care workload require further examination.
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Affiliation(s)
- Ruth Lavergne
- Associate Professor Tier II Canada Research Chair in Primary Care Department of Family Medicine Dalhousie University Halifax, NS
| | - Sandra Peterson
- Research Analyst Centre for Health Services and Policy Research University of British Columbia Vancouver, BC
| | - David Rudoler
- Associate Professor Faculty of Health Sciences Ontario Tech University Oshawa, ON Associate Professor Ontario Shores Centre for Mental Health Sciences, Whitby, ON
| | - Ian Scott
- Professor Department of Family Practice University of British Columbia Director Centre for Health Education Scholarship Vancouver, BC
| | - Rita Mccracken
- Assistant Professor Department of Family Practice University of British Columbia Vancouver, BC
| | - Goldis Mitra
- Clinical Assistant Professor Department of Family Practice University of British Columbia Vancouver, BC
| | - Alan Katz
- Professor Department of Family Medicine University of Manitoba Professor Department of Community Health Sciences University of Manitoba Winnipeg, MB
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Staples JA, Ho M, Ferris D, Liu G, Brubacher JR, Khan M, Daly-Grafstein D, Tran KC, Sutherland JM. Physician Financial Incentives for Use of Outpatient Intravenous Antimicrobial Therapy: An Interrupted Time Series Analysis. Clin Infect Dis 2023; 76:2098-2105. [PMID: 36795054 DOI: 10.1093/cid/ciad082] [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: 11/23/2022] [Revised: 01/15/2023] [Accepted: 02/09/2023] [Indexed: 02/17/2023] Open
Abstract
BACKGROUND In 2011, policymakers in British Columbia introduced a fee-for-service payment to incentivize infectious diseases physicians to supervise outpatient parenteral antimicrobial therapy (OPAT). Whether this policy increased use of OPAT remains uncertain. METHODS We conducted a retrospective cohort study using population-based administrative data over a 14-year period (2004-2018). We focused on infections that required intravenous antimicrobials for ≥10 days (eg, osteomyelitis, joint infection, endocarditis) and used the monthly proportion of index hospitalizations with a length of stay shorter than the guideline-recommended "usual duration of intravenous antimicrobials" (LOS < UDIVA) as a surrogate for population-level OPAT use. We used interrupted time series analysis to determine whether policy introduction increased the proportion of hospitalizations with LOS < UDIVA. RESULTS We identified 18 513 eligible hospitalizations. In the pre-policy period, 82.3% of hospitalizations exhibited LOS < UDIVA. Introduction of the incentive was not associated with a change in the proportion of hospitalizations with LOS < UDIVA, suggesting that the policy intervention did not increase OPAT use (step change, -0.06%; 95% confidence interval [CI], -2.69% to 2.58%; P = .97 and slope change, -0.001% per month; 95% CI, -.056% to .055%; P = .98). CONCLUSIONS The introduction of a financial incentive for physicians did not appear to increase OPAT use. Policymakers should consider modifying the incentive design or addressing organizational barriers to expanded OPAT use.
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Affiliation(s)
- John A Staples
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Centre for Clinical Epidemiology & Evaluation, Vancouver, Canada
| | - Meghan Ho
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Dwight Ferris
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Guiping Liu
- Center for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jeffrey R Brubacher
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Mayesha Khan
- Department of Medicine, University of British Columbia, Vancouver, Canada
| | - Daniel Daly-Grafstein
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Department of Statistics, University of British Columbia, Vancouver, Canada
| | - Karen C Tran
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Vancouver, Canada
| | - Jason M Sutherland
- Center for Health Services and Policy Research, School of Population and Public Health, University of British Columbia, Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences, Vancouver, Canada
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Makhinova T, Johnson JA, Minhas-Sandhu JK, Necyk C, Bhutani M, Eurich DT. Pharmacists' chronic disease management in chronic obstructive pulmonary disease: Effect on health services utilization. J Manag Care Spec Pharm 2023; 29:671-679. [PMID: 37276041 PMCID: PMC10388007 DOI: 10.18553/jmcp.2023.29.6.671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND: There is limited real-world evidence on evaluation of chronic disease management initiatives provided by pharmacists to patients with chronic obstructive pulmonary disease (COPD). OBJECTIVE: To evaluate changes in COPD-related health care resource utilization between patients with COPD who had pharmacist-provided chronic disease management (comprehensive annual care plan [CACP]) vs those who did not have CACP. METHODS: Patients with COPD who received a CACP in Alberta between 2012 and 2015 were identified within the Alberta Health administrative data. Each of these patients were matched with 2 control patients with COPD based on age, sex, provider, date of service, and qualifying comorbidities. Controlled interrupted time series analysis was used to evaluate changes in COPD-specific hospitalizations, emergency department (ED) visits, physician visits, and claims for pulmonary function test. Immediate and temporal changes were calculated for the difference in outcomes 1 year before and 1 year after receiving the CACP for the intervention group and matched controls. RESULTS: Eligible patients (N = 74,365), of whom 28,795 (38.7%) had received CACPs, were matched to a total of 45,570 controls. In 1 year after the CACPs implementation, the number of COPD-related hospitalization visits decreased by 174 (95% CI = -270.8 to -76.5) per 10,000 patients per month, COPD-related ED visits decreased by 123 (95% CI = -294.9 to 49.6) per 10,000 per month, general practitioner visits decreased by 153.9 per 10,000 per month (95% CI = -293.3 to -14.5), and pulmonary function test claims decreased by 19.5 per 10,000 per month (95% CI = -70.1 to 31.2) when compared with the matched controls. However, significant difference between the 2 groups was found for COPD-related hospitalizations only, which was not confirmed by the sensitivity analysis. CONCLUSIONS: In patients with COPD who were provided with care plans by their community pharmacists, there was no significant decrease in COPD-related hospitalizations or ED visits over 1 year compared with the matched controls who did not have a pharmacist-provided care plan. Physician visits and pulmonary function tests did not change significantly for those who had CACP compared with those who did not. There is a need to further understand how care plans can better impact other outcomes that are important in COPD management. DISCLOSURES: This study was supported by a grant from the M.S.I. Foundation (Grant#895) based in Alberta, Canada. Dr Bhutani has consulted for Astra Zeneca, GlaxoSmithKline, Boehringer Ingelheim, Valeo, Covis, and Sanofi. The authors declare no other relevant conflicts of interest or financial relationships. This study is based on data provided by Alberta Health. The interpretation and conclusions of the results are those of the researchers and do not necessarily represent the views of the government of Alberta nor the funder (M.S.I. Foundation). All authors meet criteria for authorship as recommended by the International Committee of Medical Journal Editors.
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Affiliation(s)
| | | | | | | | - Mohit Bhutani
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada
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Ride J, Kasteridis P, Gutacker N, Gravelle H, Rice N, Mason A, Goddard M, Doran T, Jacobs R. Impact of prevention in primary care on costs in primary and secondary care for people with serious mental illness. HEALTH ECONOMICS 2023; 32:343-355. [PMID: 36309945 PMCID: PMC10092448 DOI: 10.1002/hec.4623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/13/2022] [Accepted: 10/15/2022] [Indexed: 06/16/2023]
Abstract
A largely unexplored part of the financial incentive for physicians to participate in preventive care is the degree to which they are the residual claimant from any resulting cost savings. We examine the impact of two preventive activities for people with serious mental illness (care plans and annual reviews of physical health) by English primary care practices on costs in these practices and in secondary care. Using panel two-part models to analyze patient-level data linked across primary and secondary care, we find that these preventive activities in the previous year are associated with cost reductions in the current quarter both in primary and secondary care. We estimate that there are large beneficial externalities for which the primary care physician is not the residual claimant: the cost savings in secondary care are 4.7 times larger than the cost savings in primary care. These activities are incentivized in the English National Health Service but the total financial incentives for primary care physicians to participate were considerably smaller than the total cost savings produced. This suggests that changes to the design of incentives to increase the marginal reward for conducting these preventive activities among patients with serious mental illness could have further increased welfare.
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Affiliation(s)
- Jemimah Ride
- Health Economics UnitMelbourne School of Population and Global HealthUniversity of MelbourneParkvilleVictoriaAustralia
| | | | | | | | - Nigel Rice
- Centre for Health EconomicsUniversity of YorkYorkUK
| | - Anne Mason
- Centre for Health EconomicsUniversity of YorkYorkUK
| | | | - Tim Doran
- Health SciencesUniversity of YorkYorkUK
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McKayMadeleine, Lavergne MR, Prince LeaAmanda, Le M, Grudniewicz A, Blackie D, Goldsmith LJ, Marshall EG, Mathews M, McCracken R, McGrail K, Wong S, Rudoler D. Government policies targeting primary care physician practice from 1998-2018 in three Canadian provinces: A jurisdictional scan. Health Policy 2022; 126:565-575. [DOI: 10.1016/j.healthpol.2022.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 02/22/2022] [Accepted: 03/11/2022] [Indexed: 11/28/2022]
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Lavergne MR, King C, Peterson S, Simon L, Hudon C, Loignon C, McCracken RK, Brackett A, McGrail K, Strumpf E. Patient characteristics associated with enrolment under voluntary programs implemented within fee-for-service systems in British Columbia and Quebec: a cross-sectional study. CMAJ Open 2022; 10:E64-E73. [PMID: 35105683 PMCID: PMC8812717 DOI: 10.9778/cmajo.20210043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There is a paucity of information on patient characteristics associated with enrolment under voluntary programs (e.g. incentive payments) implemented within fee-for-service systems. We explored patient characteristics associated with enrolment under these programs in British Columbia and Quebec. METHODS We used linked administrative data and a cross-sectional design to compare people aged 40 years or more enrolled under voluntary programs to those who were eligible but not enrolled. We examined 2 programs in Quebec (enrolment of vulnerable patients with qualifying conditions [implemented in 2003] and enrolment of the general population [2009]) and 3 in BC (Chronic disease incentive [2003], Complex care incentive [2007] and enrolment of the general population [A GP for Me, 2013]). We used logistic regression to estimate the odds of enrolment by neighbourhood income, rural versus urban residence, previous treatment for mental illness, previous treatment for substance use disorder and use of health care services before program implementation, controlling for characteristics linked to program eligibility. RESULTS In Quebec, we identified 1 569 010 people eligible for the vulnerable enrolment program (of whom 505 869 [32.2%] were enrolled within the first 2 yr of program implementation) and 2 394 923 for the general enrolment program (of whom 352 380 [14.7%] were enrolled within the first 2 yr). In BC, we identified 133 589 people eligible for the Chronic disease incentive, 47 619 for the Complex care incentive and 1 349 428 for A GP for Me; of these, 60 764 (45.5%), 28 273 (59.4%) and 1 066 714 (79.0%), respectively, were enrolled within the first 2 years. The odds of enrolment were higher in higher-income neighbourhoods for programs without enrolment criteria (adjusted odds ratio [OR] comparing highest to lowest quintiles 1.21 [95% confidence interval (CI) 1.20-1.23] in Quebec and 1.67 [95% CI 1.64-1.69] in BC) but were similar across neighbourhood income quintiles for programs with health-related eligibility criteria. The odds of enrolment by urban versus rural location varied by program. People treated for substance use disorders had lower odds of enrolment in all programs (adjusted OR 0.60-0.72). Compared to people eligible but not enrolled, those enrolled had similar or higher numbers of primary care visits and longitudinal continuity of care in the year before enrolment. INTERPRETATION People living in lower-income neighbourhoods and those treated for substance use disorders were less likely than people in higher-income neighbourhoods and those not treated for such disorders to be enrolled in programs without health-related eligibility criteria. Other strategies are needed to promote equitable access to primary care.
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Affiliation(s)
- M Ruth Lavergne
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que.
| | - Caroline King
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Sandra Peterson
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Leora Simon
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Catherine Hudon
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Christine Loignon
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Rita K McCracken
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Austyn Brackett
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Kim McGrail
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
| | - Erin Strumpf
- Department of Family Medicine (Lavergne), Dalhousie University, Halifax, NS; Department of Epidemiology, Biostatistics and Occupational Health (King, Simon, Strumpf), McGill University, Montréal, Que.; Institut national d'excellence en santé et en services sociaux (King), Québec, Que.; Centre for Health Services and Policy Research (Peterson, McGrail), University of British Columbia, Vancouver, BC; Department of Family Medicine and Emergency Medicine (Hudon) and Faculty of Medicine and Health Sciences (Loignon), Université de Sherbrooke, Sherbrooke, Que.; Department of Family Practice (McCracken), University of British Columbia; Department of Family Medicine (McCracken), Providence Health Care; Patient Voices Network (Brackett), Vancouver, BC; Department of Economics (Strumpf), McGill University, Montréal, Que
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11
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Staples JA, Liu G, Brubacher JR, Karimuddin A, Sutherland JM. Physician Financial Incentives to Reduce Unplanned Hospital Readmissions: an Interrupted Time Series Analysis. J Gen Intern Med 2021; 36:3431-3440. [PMID: 33948803 PMCID: PMC8606373 DOI: 10.1007/s11606-021-06803-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 04/03/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND In 2012, the Ministry of Health in British Columbia, Canada, introduced a $75 incentive payment that could be claimed by hospital physicians each time they produced a written post-discharge care plan for a complex patient at the time of hospital discharge. OBJECTIVE To examine whether physician financial payments incentivizing enhanced discharge planning reduce subsequent unplanned hospital readmissions. DESIGN Interrupted time series analysis of population-based hospitalization data. PARTICIPANTS Individuals with one or more eligible hospitalizations occurring in British Columbia between 2007 and 2017. MAIN MEASURES The proportion of index hospital discharges with subsequent unplanned hospital readmission within 30 days, as measured each month of the 11-year study interval. We used interrupted time series analysis to determine if readmission risk changed after introduction of the incentive payment policy. KEY RESULTS A total of 40,588 unplanned hospital readmissions occurred among 409,289 eligible index hospitalizations (crude 30-day readmission risk, 9.92%). Policy introduction was not associated with a significant step change (0.393%; 95CI, - 0.190 to 0.975%; p = 0.182) or change-in-trend (p = 0.317) in monthly readmission risk. Policy introduction was associated with significantly fewer prescription fills for potentially inappropriate medications among older patients, but no improvement in prescription fills for beta-blockers after cardiovascular hospitalization and no change in 30-day mortality. Incentive payment uptake was incomplete, rising from 6.4 to 23.5% of eligible hospitalizations between the first and last year of the post-policy interval. CONCLUSION The introduction of a physician incentive payment was not associated with meaningful changes in hospital readmission rate, perhaps in part because of incomplete uptake by physicians. Policymakers should consider these results when designing similar interventions elsewhere. TRIAL REGISTRATION ClinicalTrials.gov ID, NCT03256734.
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Affiliation(s)
- John A. Staples
- Department of Medicine, University of British Columbia, Vancouver, Canada
- Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, Canada
- Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada
| | - Guiping Liu
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
| | - Jeffrey R. Brubacher
- Centre for Clinical Epidemiology & Evaluation (C2E2), Vancouver, Canada
- Department of Emergency Medicine, University of British Columbia, Vancouver, Canada
| | - Ahmer Karimuddin
- Department of Surgery, University of British Columbia, Vancouver, Canada
| | - Jason M. Sutherland
- Centre for Health Evaluation & Outcome Sciences (CHÉOS), Vancouver, Canada
- Centre for Health Services and Policy Research (CHSPR), School of Population and Public Health, University of British Columbia, Vancouver, Canada
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12
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Necyk C, Johnson JA, Tsuyuki RT, Eurich DT. Exploring the impact of pharmacist comprehensive annual care plans on perceived quality of chronic illness care by patients in Alberta, Canada. Can Pharm J (Ott) 2021; 154:331-341. [PMID: 34484483 PMCID: PMC8408906 DOI: 10.1177/17151635211020340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Accepted: 09/17/2020] [Indexed: 11/17/2022]
Abstract
Background: In 2012, the Government of Alberta introduced a funding program to remunerate pharmacists to develop a comprehensive annual care plan (CACP) for patients with complex needs. The objective of this study is to explore patients’ perceptions of the care they received through the pharmacist CACP program in Alberta. Methods: We invited 3442 patients who received a pharmacist-billed CACP within the previous 3 months and 6888 matched controls across Alberta to complete an online questionnaire. The questionnaire consisted of the short version Patient Assessment of Chronic Illness Care (PACIC-11), with 3 additional pharmacy-specific assessment questions added. Additional questions related to health status and demographics were also included. Results: Overall, most patients indicated a low level of chronic illness care by pharmacists, with few differences noted between CACP patients and non-CACP controls. Of note, controls reported higher quality of care for 5 domains within the adapted PACIC-like tool compared with CACP patients (p < 0.05 for all). Interestingly, only 79 (44%) of CACP patients reported that they had received a CACP, whereas only 192 (66%) of control patients reported that they did not receive a care plan. In a sensitivity analysis including only these respondents, individuals who received a CACP perceived a significantly higher quality of chronic illness care across all PACIC domains. Conclusion: Overall, chronic illness care incentivized by the pharmacist CACP program in Alberta is perceived to be moderate to low. When limited to respondents who explicitly recognized receiving the service or not, the perceptions of quality of care were more positive. This suggests that better implementation of CACP by pharmacists may be associated with improved quality of care and that some redesign is needed to engage patients more. Can Pharm J (Ott) 2021;154:xx-xx.
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Affiliation(s)
- Candace Necyk
- School of Public Health, University of Alberta, Edmonton, Alberta
| | - Jeffrey A Johnson
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta
| | - Ross T Tsuyuki
- Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta
| | - Dean T Eurich
- Faculty of Pharmacy and Pharmaceutical Sciences, University of Alberta, Edmonton, Alberta
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13
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Necyk C, Johnson JA, Minhas-Sandhu J, Tsuyuki RT, Eurich DT. Evaluation of comprehensive annual care plans by pharmacists in Alberta for patients with complex conditions. J Am Pharm Assoc (2003) 2020; 60:1029-1036.e1. [PMID: 32962900 DOI: 10.1016/j.japh.2020.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/28/2020] [Accepted: 08/17/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To characterize the population of patients who received a pharmacist-billed comprehensive annual care plan (CACP) in Alberta and to evaluate any changes in health care use for such patients, including physician visits, hospitalizations, and emergency department (ED) visits. METHODS We used administrative data from Alberta Health to identify all individuals in Alberta who received a pharmacist CACP between July 1, 2012, and March 31, 2015. Two control patients were identified for each CACP patient, matched on age, sex, provider, date of service, and qualifying conditions. Controlled interrupted time series analyses were used to evaluate changes in physician visits, all-cause and ambulatory care-sensitive condition (ACSC)-related hospitalizations, and ED visits in the 12 months before and after the CACP index date. RESULTS Between July 1, 2012, and March 31, 2015, 188,640 pharmacy CACPs were billed in Alberta. Of these, 137,178 CACP patients were matched to 241,658 control patients. Those who received a CACP were associated with an overall decrease in all-cause hospitalizations, ACSC-related ED visits, and physician visits (181, 144, and 1206 events per 10,000 people, respectively, P < 0.05) compared with controls. However, among those who received a CACP, all-cause ED visits and ACSC-related hospitalizations increased by 40.1 and 8 visits per 10,000, respectively (P < 0.05), compared with controls. CONCLUSION The uptake of the pharmacy CACP remuneration model has been substantial since 2012. Overall, the CACP philosophy of a single yearly assessment has demonstrated limited impact on major health care use.
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14
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Uptake of the Heart Failure Management Incentive Billing Code by Family Physicians in Ontario, Canada: A Retrospective Cohort Study. Can J Cardiol 2020; 37:508-512. [PMID: 32882329 DOI: 10.1016/j.cjca.2020.08.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 08/21/2020] [Accepted: 08/27/2020] [Indexed: 11/24/2022] Open
Abstract
In 2008, the Ontario Ministry of Health and Long-Term Care (MOHLTC) implemented an incentive payment, Q050A billing code, to family physicians for provision of comprehensive guideline-based care for patients with heart failure in the community. Our objective was to report on the uptake of this program from fiscal years 2008-2014. We determined the numbers of claims billed per year and the proportion of eligible patients with congestive heart failure (CHF) for whom a physician billed. The code was billed by 10.4% of all family physicians in 2008-2009, which increased to 15.1% in 2014-2015. The code was claimed for 4.1% of all identified patients with CHF in 2008-2009 and 5.9% of patients with CHF in 2014-2015. Given these findings, it is estimated that MOHLTC paid an additional CAD$10,118,514 to family physicians managing patients with CHF. This is the first study to examine the uptake of a CHF-specific incentive program, which will help to inform health policy makers in implementing such programs in Ontario.
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15
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McGrail K, Lavergne MR, Ahuja M, Yung S, Peterson S. Patient and primary care physician characteristics associated with billing incentives for chronic diseases in British Columbia: a retrospective cohort study. CMAJ Open 2020; 8:E319-E327. [PMID: 32371526 PMCID: PMC7207028 DOI: 10.9778/cmajo.20190054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Incentive payments for chronic diseases in British Columbia were intended to support primary care physicians in providing more comprehensive care, but research shows that not all physicians bill incentives and not all eligible patients have them billed on their behalf. We investigated patient and physician characteristics associated with billing incentives for chronic diseases in BC. METHODS We conducted a retrospective cohort analysis using linked administrative health data to examine community-based primary care physicians and patients with eligible chronic conditions in BC during 2010-2013. Descriptive analyses of patients and physicians compared 3 groups: no incentives in any of the 4 years, incentives in all 4 years, and incentives in any of the study years. We used hierarchical logistic regression models to identify the patient- and physician-level characteristics associated with billing incentives. RESULTS Of 428 770 eligible patients, 142 475 (33.2%) had an incentive billed on their behalf in all 4 years, and 152 686 (35.6%) never did. Of 3936 physicians, 2625 (66.7%) billed at least 1 incentive in each of the 4 years, and 740 (18.8%) billed no incentives during the study period. The strongest predictors of having an incentive billed were the number of physician contacts a patient had (odds ratio [OR] for > 48 contacts 134.77, 95% confidence interval [CI] 112.27-161.78) and whether a physician had a large number of patients in his or her practice for whom incentives were billed (OR 42.38 [95% CI 34.55-52.00] for quartile 4 v. quartile 1). INTERPRETATION The findings suggest that primary care physicians bill incentives for patients based on whom they see most often rather than using a population health management approach to their practice.
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Affiliation(s)
- Kimberlyn McGrail
- Centre for Health Services and Policy Research (McGrail, Ahuja, Yung, Peterson), School of Population and Public Health, University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC
| | - M Ruth Lavergne
- Centre for Health Services and Policy Research (McGrail, Ahuja, Yung, Peterson), School of Population and Public Health, University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC
| | - Megan Ahuja
- Centre for Health Services and Policy Research (McGrail, Ahuja, Yung, Peterson), School of Population and Public Health, University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC
| | - Seles Yung
- Centre for Health Services and Policy Research (McGrail, Ahuja, Yung, Peterson), School of Population and Public Health, University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC
| | - Sandra Peterson
- Centre for Health Services and Policy Research (McGrail, Ahuja, Yung, Peterson), School of Population and Public Health, University of British Columbia, Vancouver, BC; Faculty of Health Sciences (Lavergne), Simon Fraser University, Burnaby, BC
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16
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Gupta N, Ayles HM. Effects of pay-for-performance for primary care physicians on diabetes outcomes in single-payer health systems: a systematic review. THE EUROPEAN JOURNAL OF HEALTH ECONOMICS : HEPAC : HEALTH ECONOMICS IN PREVENTION AND CARE 2019; 20:1303-1315. [PMID: 31401699 DOI: 10.1007/s10198-019-01097-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2019] [Accepted: 07/31/2019] [Indexed: 06/10/2023]
Abstract
BACKGROUND Although pay-for-performance (P4P) for diabetes care is increasingly common, evidence of its effectiveness in improving population health and health system sustainability is deficient. This information gap is attributable in part to the heterogeneity of healthcare financing, covered medical conditions, care settings, and provider remuneration arrangements within and across countries. We systematically reviewed the literature concentrating on whether P4P for physicians in primary and community care leads to better diabetes outcomes in single-payer national health insurance systems. METHODS Studies were identified by searching ten databases (01/2000-04/2018) and scanning the reference lists of review articles and other global health literature. We included primary studies evaluating the effects of introducing P4P for diabetes care among primary care physicians in countries of universal health coverage. Outcomes of interest included patient morbidity, avoidable hospitalization, premature death, and healthcare costs. RESULTS We identified 2218 reports; after exclusions, 10 articles covering 8 P4P interventions in 7 countries were eligible for analysis. Five studies, capturing records from 717,166 patients with diabetes, were graded as high-quality evaluations of P4P on health outcomes. Based on three quality studies, P4P can result in reduced risk of mortality over the longer term-when linked to performance metrics. However, studies from other jurisdictions, where P4P was not linked to specific patient-oriented objectives, yielded little or mixed evidence of positive health impacts. CONCLUSION Evidence of the effectiveness of P4P depends on whether physicians' incentive payments are explicitly tied to performance metrics. However, the most appropriate indicators for performance monitoring remain in question. More research with rigorous evaluation in different settings is needed.
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Affiliation(s)
- Neeru Gupta
- University of New Brunswick, PO Box 4400, Fredericton, NB, E3B 5A3, Canada.
| | - Holly M Ayles
- University of New Brunswick, PO Box 4400, Fredericton, NB, E3B 5A3, Canada
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17
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Fisher A, Carney G, Bassett K, Maclure KM, Dormuth CR. Policy-induced selection bias in pharmacoepidemiology: The example of coverage for Alzheimer's medications in British Columbia. Pharmacoepidemiol Drug Saf 2019; 28:1067-1076. [PMID: 31267629 PMCID: PMC6771502 DOI: 10.1002/pds.4804] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 04/16/2019] [Accepted: 04/19/2019] [Indexed: 11/07/2022]
Abstract
PURPOSES To assess the impact of a government-sponsored reimbursement policy for cholinesterase inhibitors (ChEIs) on trends in physician visits with a diagnosis of Alzheimer's disease (AD). METHODS Longitudinal population-based study using interrupted time series methods. British Columbia outpatient claims data for individuals aged 65 and older were used to compute monthly AD visit rates and examine the impact of the ChEI reimbursement policy on the coding of AD. We examined trends in the number of patients with AD visits, the number of AD visits per patient, and visits with "competing" diagnoses (mental, neurological, and cerebrovascular disorders and accidental falls). Finally, we described demographic and clinical features of diagnosed patients. RESULTS We analyzed 1.9 million AD visits. Faster growth in recorded AD visits was observed after the policy was implemented, from monthly growth of 7.5 visits per 100 000 person-months before the policy (95% confidence interval [CI], 6.1-8.9) to monthly growth of 16.5 per 100 000 person-months after the policy (95% CI, 14.8-18.3). After the implementation of the policy, we observed increased growth in the number of patients with recorded AD visits and the number of AD visits per patient, as well as a shift in diagnoses away from mental diseases and accidental falls to AD (diagnosis substitution). CONCLUSIONS British Columbia's reimbursement policy for ChEIs was associated with a significant acceleration in Alzheimer's visits. Evaluations of health services utilization and clinical outcomes following drug policy changes need to consider policy-induced influences on the reliability of the data used in the analysis.
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Affiliation(s)
- Anat Fisher
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Greg Carney
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ken Bassett
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada.,Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - K Malcolm Maclure
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Colin R Dormuth
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
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18
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Knight JC, Moineddin R, Mathews M, Aubrey-Bassler K. Effect of primary health care reforms in the province of Newfoundland and Labrador: Interrupted time-series analysis. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2019; 65:e296-e304. [PMID: 31300443 PMCID: PMC6738472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To examine the effects of primary health care (PHC) reforms in the Canadian province of Newfoundland and Labrador on ambulatory care-sensitive (ACS) hospitalization rates and mortality. DESIGN Interrupted time-series analysis of administrative data. SETTING All communities in the province of Newfoundland and Labrador were divided into 3 groups: rural reform (n = 69 143), rural nonreform (n = 228 914), and urban nonreform (n = 197 012). No urban communities introduced PHC reforms. PARTICIPANTS All residents of the province who held a valid health card and did not change their address during the 2001-2009 study period were included. Individuals were assigned to 1 of the 3 study groups based on community of residence. MAIN OUTCOME MEASURES Hospitalization rates for ACS conditions, hospitalization rates for control conditions, and ACS-related mortality were compared using interrupted time-series models. RESULTS Results are reported as rate ratio or odds ratio (OR) (95% CI). In rural reform and rural nonreform communities, there was a decreasing trend in ACS hospitalization rates that preceded reforms (rate ratio of 0.97 [0.94-1.00]) and rate ratio of 0.98 [0.96-1.00], respectively) but no change following reforms. There were no significant changes in the urban group. In all 3 groups, there was a significant increasing trend in ACS-related mortality before reforms (OR of 1.09 [1.02-1.15], OR of 1.10 [1.06-1.13], and OR of 1.09 [1.05-1.14] for rural reform, rural nonreform, and urban communities, respectively), which was reversed after the introduction of reforms (P < .01). CONCLUSION Primary health care reforms in Newfoundland and Labrador had no observed effect on ACS hospitalization rates, but a potential effect might have been masked by a decreasing trend that preceded the introduction of reforms. The increase in mortality rates that was reversed after the introduction of reforms cannot be attributed to the reforms because it occurred in all studied populations including those that did not introduce reforms.
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Affiliation(s)
- John C Knight
- Research Associate in the Primary Healthcare Research Unit and Adjunct Professor in the Division of Community Health and Humanities at Memorial University of Newfoundland in St John's, and Senior Epidemiologist in the Health Analytics and Evaluation Services Department in the Newfoundland and Labrador Centre for Health Information
| | - Rahim Moineddin
- Professor in the Department of Family and Community Medicine and in the Biostatistics Division at the Dalla Lana School of Public Health at the University of Toronto in Ontario
| | - Maria Mathews
- At the time of writing, Dr Mathews was Professor in the Division of Community Health and Humanities at Memorial University of Newfoundland
| | - Kris Aubrey-Bassler
- Associate Professor in the Discipline of Family Medicine and Director of the Primary Healthcare Research Unit at Memorial University of Newfoundland.
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19
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Gupta N, Lavallée R, Ayles J. Gendered effects of pay for performance among family physicians for chronic disease care: an economic evaluation in a context of universal health coverage. HUMAN RESOURCES FOR HEALTH 2019; 17:40. [PMID: 31151400 PMCID: PMC6544935 DOI: 10.1186/s12960-019-0378-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Accepted: 05/13/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND Despite increasing popularity among health organizations of pay for performance (P4P) for the provision of comprehensive care for chronic non-communicable diseases, evidence of its effectiveness in improving health system outcomes is weak. An important void in the evidence base is whether there are gendered differences in P4P uptake and in related outcomes amenable to healthcare improvement. This study assesses the gender-specific effects of P4P among family physicians on diabetes healthcare costs in a context of universal health coverage. METHODS We use population-based linked longitudinal administrative datasets on chronic disease cases, physician billings, hospital discharge abstracts, and physician and resident registries in the province of New Brunswick, Canada. We estimate the effects of introduction of a P4P scheme on excess public healthcare costs among cohorts of adult diabetes patients using propensity score-adjusted difference-in-differences regressions stratified by physician's gender. RESULTS We observed greater male physician uptake of incentive payments, seemingly exacerbating gender gaps in professional remuneration. Regression results indicated P4P did not lead to improved outcomes in terms of preventing hospitalization costs among patients, only measurable increases in compensation for both the male and female physician workforce. CONCLUSIONS While P4P was not attributed in this study to reduced hospital burden and enhanced sustainability of healthcare financing, incentive payments were found to be related to earning gaps by physician's gender. Decision-makers should consider that benefits of P4P be monitored not only for patient metrics but also for provider metrics in terms of gender equality especially given feminization of primary care medical workforces.
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Affiliation(s)
- Neeru Gupta
- University of New Brunswick, 3 Bailey Drive, Fredericton, New Brunswick Canada
| | - René Lavallée
- New Brunswick Department of Health, 520 King Street, Fredericton, New Brunswick Canada
| | - James Ayles
- New Brunswick Department of Health, 520 King Street, Fredericton, New Brunswick Canada
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McCormick N, Hamilton CB, Koehn CL, English K, Stordy A, Li LC. Canadians' views on the use of routinely collected data in health research: a patient-oriented cross-sectional survey. CMAJ Open 2019; 7:E203-E209. [PMID: 30948649 PMCID: PMC6450795 DOI: 10.9778/cmajo.20180105] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Little is known about Canadians' knowledge of and level of support for using administrative and other large, routinely collected data for health research, despite the benefits of this type of research to patients, health care systems and society. We sought to benchmark the views of Canadian adults on this topic. METHODS Researchers and patient leaders of 3 joint and skin disease organizations codeveloped a cross-sectional online survey that was conducted between January and August 2017. The patient partners were engaged as full partners. Recruitment was mainly through the organizations' websites, email and social media. The survey captured respondents' initial perceptions, then (after background information on the topic was provided) elicited their views on the benefits of health research using routinely collected data, data access/privacy concerns, ongoing perceptions and educational needs. RESULTS Of the 230 people who consented, 183 (79.6%) started the survey, and 151 (65.6%) completed the survey. Of the 151, 117 (77.5%) were women, 84 (55.6%) were British Columbians, 87 (57.6%) were university graduates, and 101 (66.9%) had a chronic disease. At the beginning of the survey, 119 respondents (78.8%) felt positively about the use of routinely collected data for health research. Respondents identified the ability to study long-term treatment effects and rare events (114 [75.5%]) and large numbers of people (110 [72.8%]) as key benefits. Deidentification of personal information was the top privacy measure (135 [89.4%]), and 101 respondents (66.9%) wanted to learn more about data stewards' granting access to data. On survey completion, more respondents (141 [93.4%]) felt positively about the use of routinely collected data, but only 87 (57.6%) were confident about data security and privacy. INTERPRETATION Respondents generally supported the use of deidentified routinely collected data for health research. Although further investigation is needed with more representative samples, our findings suggest that additional education, especially about access and privacy controls, may enhance public support for research endeavours using these data.
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Affiliation(s)
- Natalie McCormick
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Clayon B Hamilton
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Cheryl L Koehn
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Kelly English
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Allan Stordy
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta
| | - Linda C Li
- Arthritis Research Canada (McCormick, Hamilton, Li), Richmond, BC; Department of Physical Therapy (Hamilton, Li), University of British Columbia; Arthritis Consumer Experts (Koehn), Vancouver, BC; Arthritis Patients Advisory Board (English), Arthritis Research Canada, Richmond, BC; Canadian Skin Patient Alliance (Stordy), Calgary, Alta.
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Glazier RH, Green ME, Frymire E, Kopp A, Hogg W, Premji K, Kiran T. Do Incentive Payments Reward The Wrong Providers? A Study Of Primary Care Reform In Ontario, Canada. Health Aff (Millwood) 2019; 38:624-632. [DOI: 10.1377/hlthaff.2018.05272] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Richard H. Glazier
- Richard H. Glazier is a senior scientist in the Primary Care and Population Health Program at ICES (formerly known as the Institute for Clinical Evaluative Sciences) in Toronto, Ontario. He is also a clinician scientist in the Department of Family and Community Medicine at the University of Toronto and at St. Michael’s Hospital in Toronto
| | - Michael E. Green
- Michael E. Green is the Brian Hennen Chair and head of the Department of Family Medicine, Faculty of Health Sciences, Queen’s University, in Kingston, Ontario. He is also a senior adjunct scientist at ICES and is the clinical head at Kingston Health Sciences Centre and Providence Care Hospital
| | - Eliot Frymire
- Eliot Frymire is a project manager in the Primary Care and Population Health Program, ICES, in Kingston. He is also the research manager at the Health Services and Policy Research Institute, Queen’s University
| | - Alex Kopp
- Alex Kopp is a senior research methodologist in the Primary Care and Population Health Program at ICES in Toronto
| | - William Hogg
- William Hogg is a senior research adviser in the C. T. Lamont Primary Health Care Research Centre, Elisabeth Bruyere Research Institute, in Ottawa, Ontario
| | - Kamila Premji
- Kamila Premji is a family physician at Central Ottawa Family Medicine Associates, in Ottawa. She is also a PhD candidate at Western University’s Centre for Studies in Family Medicine, in London, and a clinical lead in the Champlain Local Health Integration Network, in Ottawa
| | - Tara Kiran
- Tara Kiran is the Fidani Chair in Improvement and Innovation and vice chair for quality and innovation in the Department of Family and Community Medicine, University of Toronto. She is also a clinician scientist in the Department of Family and Community Medicine at the University of Toronto and at St. Michael’s Hospital in Toronto, and an embedded researcher at Health Quality Ontario
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Hedden L, Lavergne MR, McGrail KM, Law MR, Bourgeault IL, McCracken R, Barer ML. Trends in Providing Out-of-Office, Urgent After-Hours, and On-Call Care in British Columbia. Ann Fam Med 2019; 17:116-124. [PMID: 30858254 PMCID: PMC6411390 DOI: 10.1370/afm.2366] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Revised: 10/23/2018] [Accepted: 12/17/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Providing care in alternative (non-office) locations and outside office hours are important elements of access and comprehensiveness of primary care. We examined the trends in and determinants of the services provided in a cohort of primary care physicians in British Columbia, Canada. METHODS We used physician-level payments for all primary care physicians practicing in British Columbia from 2006-2007 through 2011-2012. We examined the association between physician demographics and practice characteristics and payment for care in alternative locations and after hours across rural, urban, and metropolitan areas using longitudinal mixed-effects models. RESULTS The proportion of physicians who provided care in alternative locations and after hours declined significantly during the period, in rural, urban, and metropolitan practices. Declines ranged from 5% for long-term care facility visits to 22% for after-hours care. Female physicians, and those in the oldest age category, had lower odds of providing care at alternative locations and for urgent after-hours care. Compared with those practicing in metropolitan centers, physicians working in rural areas had significantly higher odds of providing care both in alternative locations and after hours. CONCLUSION Care provided in non-office locations and after office hours declined significantly during the study period. Jurisdictions where providing these services are not mandated, and where similar workforce demographic shifts are occurring, may experience similar accessibility challenges.
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Affiliation(s)
- Lindsay Hedden
- Centre for Clinical Epidemiology and Evaluation, Research Pavilion, Vancouver General Hospital, Vancouver, British Columbia, Canada
| | - M Ruth Lavergne
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Kimberlyn M McGrail
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Michael R Law
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ivy L Bourgeault
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
| | - Rita McCracken
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
| | - Morris L Barer
- Centre for Health Services and Policy Research, University of British Columbia, Vancouver, British Columbia, Canada
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Gupta N, Lavallée R, Ayles J. Effects of Pay-for-Performance for Primary Care Physicians on Preventable Diabetes-Related Hospitalization Costs Among Adults in New Brunswick, Canada: A Quasiexperimental Evaluation. Can J Diabetes 2018; 43:354-360.e1. [PMID: 30679059 DOI: 10.1016/j.jcjd.2018.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 11/15/2018] [Accepted: 11/19/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES In New Brunswick, Canada, 13.6% of the population 35 years of age and older is living with type 1 or type 2 diabetes mellitus. To address public health and clinical challenges, pay-for-performance (P4P) for family physicians was introduced in 2010 to enable comprehensive diabetes management. This study assesses the impacts of the P4P scheme on excess health-care costs. METHODS We used a quasiexperimental study design drawing on linked population-based administrative data sets of physician billings, hospital discharge abstracts and provider and resident registrations. Prospective cohorts of patients with diabetes were identified through a validated algorithm tracing individuals' interactions with the health-care system. We applied propensity-score difference-in-differences estimation for the effects of P4P on preventable diabetes-related hospitalization costs according to patients' exposures to physicians' uptake of the incentive. RESULTS Coverage of incentivized care peaked at less than half (44%) of adults with diabetes, who tended to be younger and less often presenting comorbid conditions compared to those whose providers did not claim incentives. The introduction of P4P was attributed to significantly lower diabetes hospitalization costs among newly diagnosed patients (-0.083; p<0.01) and improved compensation for physicians. No cost avoidance was established among medium-term and longer-term patients or for hospitalizations for conditions concordant with diabetes. CONCLUSIONS The effects of New Brunswick's P4P for diabetes care are mixed. Results reflect the deficient evidence base on the effects of P4P on patient-oriented and policymaker-important health outcomes. The high risk for multiple morbidities among patients with diabetes and the heterogeneity of physician responses to performance incentives may be hindering the effectiveness of P4P in improving diabetes outcomes.
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Affiliation(s)
- Neeru Gupta
- University of New Brunswick, Department of Sociology, Fredericton, New Brunswick, Canada.
| | - René Lavallée
- Government of New Brunswick, Department of Health, Fredericton, New Brunswick, Canada
| | - James Ayles
- Government of New Brunswick, Department of Health, Fredericton, New Brunswick, Canada
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24
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Ivers NM, Dhalla I, Brown A. Aligning innovations in health funding with innovations in care. CMAJ 2018; 190:E957-E960. [PMID: 30104189 DOI: 10.1503/cmaj.171312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Affiliation(s)
- Noah M Ivers
- Women's College Research Institute and Institute for Health System Solutions and Virtual Care (Ivers), Women's College Hospital; Department of Family and Community Medicine (Ivers), University of Toronto; Institute of Health Policy, Management and Evaluation (Ivers, Dhalla), Dalla Lana School of Public Health, University of Toronto; Health Quality Ontario (Dhalla); Department of Medicine (Dhalla), St. Michael's Hospital and University of Toronto; Dalla Lana School of Public Health (Brown), University of Toronto, Toronto, Ont.
| | - Irfan Dhalla
- Women's College Research Institute and Institute for Health System Solutions and Virtual Care (Ivers), Women's College Hospital; Department of Family and Community Medicine (Ivers), University of Toronto; Institute of Health Policy, Management and Evaluation (Ivers, Dhalla), Dalla Lana School of Public Health, University of Toronto; Health Quality Ontario (Dhalla); Department of Medicine (Dhalla), St. Michael's Hospital and University of Toronto; Dalla Lana School of Public Health (Brown), University of Toronto, Toronto, Ont
| | - Adalsteinn Brown
- Women's College Research Institute and Institute for Health System Solutions and Virtual Care (Ivers), Women's College Hospital; Department of Family and Community Medicine (Ivers), University of Toronto; Institute of Health Policy, Management and Evaluation (Ivers, Dhalla), Dalla Lana School of Public Health, University of Toronto; Health Quality Ontario (Dhalla); Department of Medicine (Dhalla), St. Michael's Hospital and University of Toronto; Dalla Lana School of Public Health (Brown), University of Toronto, Toronto, Ont
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25
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Glazier RH. Reflections of the quality of primary care in Canada and Israel. Isr J Health Policy Res 2018; 7:46. [PMID: 30075816 PMCID: PMC6091009 DOI: 10.1186/s13584-018-0243-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Accepted: 07/29/2018] [Indexed: 11/10/2022] Open
Affiliation(s)
- Richard H Glazier
- Institute for Clinical Evaluative Sciences, Toronto, Canada. .,Centre for Urban Health Solutions at St. Michael's Hospital, Toronto, Canada. .,Family and Community Medicine at St, Michael's Hospital and University of Toronto, Toronto, Canada.
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Hedden L, Barer ML, McGrail K, Law M, Bourgeault IL. In British Columbia, The Supply Of Primary Care Physicians Grew, But Their Rate Of Clinical Activity Declined. Health Aff (Millwood) 2018; 36:1904-1911. [PMID: 29137511 DOI: 10.1377/hlthaff.2017.0014] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Reports of a primary care shortage are ubiquitous in Canada and the United States. We used a population-based, retrospective cohort study to examine the extent to which the feminization and aging of the primary care physician workforce and secular trends may contribute to changes in the availability of primary care services. We used billing data for all primary care physicians in British Columbia for the period 2005-12. We used multivariate linear mixed-effects models to study physician remuneration and activity levels. We found limited change in per physician remuneration over the study period. However, numbers of patient contacts and practice sizes (numbers of unique patients) declined by 14 percent and 10 percent, respectively. Although the feminization of the workforce-and, to a lesser extent, its aging-contributed to this decline, the primary driver appears to be a broad trend toward reduced clinical activity over time. To the extent that similar trends are occurring in the United States, the implications of our study for the availability of primary care services beyond Canada are potentially significant.
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Affiliation(s)
- Lindsay Hedden
- Lindsay Hedden ( ) is a postdoctoral fellow in the Centre for Clinical Epidemiology and Evaluation, School of Population and Public Health, University of British Columbia, in Vancouver
| | - Morris L Barer
- Morris L. Barer is a professor in the Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia
| | - Kimberlyn McGrail
- Kimberlyn McGrail is an associate professor in the Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia
| | - Michael Law
- Michael Law is an associate professor in the Centre for Health Services and Policy Research, School of Population and Public Health, University of British Columbia
| | - Ivy L Bourgeault
- Ivy L. Bourgeault is a professor in the Telfer School of Management, University of Ottawa, in Ontario
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Stokes J, Struckmann V, Kristensen SR, Fuchs S, van Ginneken E, Tsiachristas A, Rutten van Mölken M, Sutton M. Towards incentivising integration: A typology of payments for integrated care. Health Policy 2018; 122:963-969. [PMID: 30033204 DOI: 10.1016/j.healthpol.2018.07.003] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/29/2018] [Accepted: 07/01/2018] [Indexed: 11/26/2022]
Abstract
Traditional provider payment mechanisms may not create appropriate incentives for integrating care. Alternative payment mechanisms, such as bundled payments, have been introduced without uniform definitions, and existing payment typologies are not suitable for describing them. We use a systematic review combined with example integrated care programmes identified from practice in the Horizon2020 SELFIE project to inform a new typology of payment mechanisms for integrated care. The typology describes payments in terms of the scope of payment (Target population, Time, Sectors), the participation of providers (Provider coverage, Financial pooling/sharing), and the single provider/patient involvement (Income, Multiple disease/needs focus, and Quality measurement). There is a gap between rhetoric on the need for new payment mechanisms and those implemented in practice. Current payments for integrated care are mostly sector- and disease-specific, with questionable impact on those with the most need for integrated care. The typology provides a basis to improve financial incentives supporting more effective and efficient integrated care systems.
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Affiliation(s)
- Jonathan Stokes
- Manchester Centre for Health Economics, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, United Kingdom.
| | - Verena Struckmann
- Berlin University of Technology, Department of Health Care Management, Straße des 17.Juni 135, Berlin 10623, Germany.
| | - Søren Rud Kristensen
- Manchester Centre for Health Economics, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, United Kingdom; Centre for Health Policy, Institute of Global Health Innovation, Imperial College London, United Kingdom.
| | - Sabine Fuchs
- Department of Health Care Management, Berlin University of Technology, Straße des 17. Juni 135, Berlin 10623, Germany.
| | - Ewout van Ginneken
- European Observatory on Health Systems and Policies, Berlin University of Technology, Strasse des 17. Juni 135, Berlin 10623, Germany.
| | - Apostolos Tsiachristas
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford OX3 7LF, United Kingdom.
| | - Maureen Rutten van Mölken
- Erasmus School of Health Policy and Management and Institute for Medical Technology Assessment, Erasmus University Rotterdam, P.O. Box 1738, Rotterdam 3000 DR, The Netherlands.
| | - Matt Sutton
- Manchester Centre for Health Economics, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester M13 9PL, United Kingdom.
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Li Z, Yang J, Wu Y, Pan Z, He X, Li B, Zhang L. Challenges for the surgical capacity building of township hospitals among the Central China: a retrospective study. Int J Equity Health 2018; 17:55. [PMID: 29720175 PMCID: PMC5932883 DOI: 10.1186/s12939-018-0766-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 04/16/2018] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND China's rapid transition in healthcare service system has posed considerable challenges for the primary care system. Little is known regarding the capacity of township hospitals (THs) to deliver surgical care in rural China with over 600 million lives. We aimed to ascertain its current performance, barriers, and summary lessons for its re-building in central China. METHODS This study was conducted in four counties from two provinces in central China. The New Rural Cooperative Medical System (NRCMS) claim data from two counties in Hubei province was analyzed to describe the current situation of surgical care provision. Based on previous studies, self-administered questionnaire was established to collect key indicators from 60 THs from 2011 to 2015, and social and economic statuses of the sampling townships were collected from the local statistical yearbook. Semi-structured interviews were conducted among seven key administrators in the THs that did not provide appendectomy care in 2015. Determinants of appendectomy care provision were examined using a negative binominal regression model. RESULTS First, with the rapid increase in inpatient services provided by the THs, their proportion of surgical service provision has been nibbled by out-of-county facilities. Second, although DY achieved a stable performance, the total amount of appendectomy provided by the 60 THs decreased to 589 in 2015 from 1389 in 2011. Moreover, their proportion reduced to 26.77% in 2015 from 41.84% in 2012. Third, an increasing number of THs did not provide appendectomy in 2015, with the shortage of anesthesiologists and equipment as the most mentioned reasons (46.43%). Estimation results from the negative binomial model indicated that the annual average per capita disposable income and tightly integrated delivery networks (IDNs) negatively affected the amount of appendectomy provided by THs. By contrast, the probability of appendectomy provision by THs was increased by performance-related payment (PRP). Out-of-pocket (OOP) cost gap of appendectomy services between the two different levels of facilities, payment method, and the size of THs presented no observable improvement to the likelihood of appendectomy care in THs. CONCLUSION The county-level health system did not effectively respond to the continuously increasing surgical care need. The surgical capacity of THs declined with the surgical patterns' simplistic and quantity reduction. Deficits and critical challenges for surgical capacity building in central China were identified, including shortage of human resources and medical equipment and increasing income. Moreover, tight IDNs do not temporarily achieve capacity building. Therefore, the reimbursement rate should be further ranged, and physicians should be incentivized appropriately. The administrators, policy makers, and medical staff of THs should be aware of these findings owing to the potential benefits for the capacity building of the rural healthcare system.
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Affiliation(s)
- Zhong Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Jian Yang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
- Department of Medical Affairs, Guangdong General Hospital, Guangzhou, 510080 Guangdong China
| | - Yue Wu
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Zijin Pan
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Xiaoqun He
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Boyang Li
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
| | - Liang Zhang
- School of Medicine and Health Management, Tongji Medical College, Huazhong University of Science and Technology, No 13 Hangkong Road, Qiaokou District Wuhan, Hubei, 430030 China
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McAlister FA, Bakal JA, Green L, Bahler B, Lewanczuk R. The effect of provider affiliation with a primary care network on emergency department visits and hospital admissions. CMAJ 2018; 190:E276-E284. [PMID: 29530868 PMCID: PMC5849446 DOI: 10.1503/cmaj.170385] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/23/2017] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Primary care networks are designed to facilitate access to inter-professional, team-based care. We compared health outcomes associated with primary care networks versus conventional primary care. METHODS We obtained data on all adult residents of Alberta who visited a primary care physician during fiscal years 2008 and 2009 and classified them as affiliated with a primary care network or not, based on the physician most involved in their care. The primary outcome was an emergency department visit or nonelective hospital admission for a Patient Medical Home indicator condition (asthma, chronic obstructive pulmonary disease, heart failure, coronary disease, hypertension and diabetes) within 12 months. RESULTS Adults receiving care within a primary care network (n = 1 502 916) were older and had higher comorbidity burdens than those receiving conventional primary care (n = 1 109 941). Patients in a primary care network were less likely to visit the emergency department for an indicator condition (1.4% v. 1.7%, mean 0.031 v. 0.035 per patient, adjusted risk ratio [RR] 0.98, 95% confidence interval [CI] 0.96-0.99) or for any cause (25.5% v. 30.5%, mean 0.55 v. 0.72 per patient, adjusted RR 0.93, 95% CI 0.93-0.94), but were more likely to be admitted to hospital for an indicator condition (0.6% v. 0.6%, mean 0.018 v. 0.017 per patient, adjusted RR 1.07, 95% CI 1.03-1.11) or all-cause (9.3% v. 9.1%, mean 0.25 v. 0.23 per patient, adjusted RR 1.08, 95% CI 1.07-1.09). Patients in a primary care network had 169 fewer all-cause emergency department visits and 86 fewer days in hospital (owing to shorter lengths of stay) per 1000 patient-years. INTERPRETATION Care within a primary care network was associated with fewer emergency department visits and fewer hospital days.
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Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine (McAlister) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Bakal), Alberta SPOR Support Unit Data Platform; Department of Family Medicine (Green); Department of Medicine (Lewanczuk), University of Alberta and Primary Health Care, Alberta Health Services (Bahler), Edmonton, Alta.
| | - Jeffrey A Bakal
- Division of General Internal Medicine (McAlister) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Bakal), Alberta SPOR Support Unit Data Platform; Department of Family Medicine (Green); Department of Medicine (Lewanczuk), University of Alberta and Primary Health Care, Alberta Health Services (Bahler), Edmonton, Alta
| | - Lee Green
- Division of General Internal Medicine (McAlister) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Bakal), Alberta SPOR Support Unit Data Platform; Department of Family Medicine (Green); Department of Medicine (Lewanczuk), University of Alberta and Primary Health Care, Alberta Health Services (Bahler), Edmonton, Alta
| | - Brad Bahler
- Division of General Internal Medicine (McAlister) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Bakal), Alberta SPOR Support Unit Data Platform; Department of Family Medicine (Green); Department of Medicine (Lewanczuk), University of Alberta and Primary Health Care, Alberta Health Services (Bahler), Edmonton, Alta
| | - Richard Lewanczuk
- Division of General Internal Medicine (McAlister) and Patient Health Outcomes Research and Clinical Effectiveness Unit (McAlister, Bakal), Alberta SPOR Support Unit Data Platform; Department of Family Medicine (Green); Department of Medicine (Lewanczuk), University of Alberta and Primary Health Care, Alberta Health Services (Bahler), Edmonton, Alta
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Expanding the breadth of Medicare: learning from Australia. HEALTH ECONOMICS POLICY AND LAW 2018; 13:344-368. [DOI: 10.1017/s1744133117000421] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractThe design of Australia’s Medicare programme was based on the Canadian scheme, adapted somewhat to take account of differences in the constitutional division of powers in the two countries and differences in history. The key elements are very similar: access to hospital services without charge being the core similarity, universal coverage for necessary medical services, albeit with a variable co-payment in Australia, the other. But there are significant differences between the two countries in health programmes – whether or not they are labelled as ‘Medicare’. This paper discusses four areas where Canada could potentially learn from Australia in a positive way. First, Australia has had a national Pharmaceutical Benefits Scheme for almost 70 years. Second, there have been hesitant extensions to Australia’s Medicare to address the increasing prevalence of people with chronic conditions – extensions which include some payments for allied health professionals, ‘care coordination’ payments, and exploration of ‘health care homes’. Third, Australia has a much more extensive system of support for older people to live in their homes or to move into supported residential care. Fourth, Australia has gone further in driving efficiency in the hospital sector than has Canada. Finally, the paper examines aspects of the Australian health care system that Canada should avoid, including the very high level of out-of-pocket costs, and the role of private acute inpatient provision.
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Rudoler D, de Oliveira C, Cheng J, Kurdyak P. Payment incentives for community-based psychiatric care in Ontario, Canada. CMAJ 2017; 189:E1509-E1516. [PMID: 29229712 DOI: 10.1503/cmaj.160816] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/20/2017] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND In September 2011, the government of Ontario implemented payment incentives to encourage the delivery of community-based psychiatric care to patients after discharge from a psychiatric hospital admission and to those with a recent suicide attempt. We evaluated whether these incentives affected supply of psychiatric services and access to care. METHODS We used administrative data to capture monthly observations for all psychiatrists who practised in Ontario between September 2009 and August 2014. We conducted interrupted time-series analyses of psychiatrist-level and patient-level data to evaluate whether the incentives affected the quantity of eligible outpatient services delivered and the likelihood of receiving follow-up care. RESULTS Among 1921 psychiatrists evaluated, implementation of the incentive payments was not associated with increased provision of follow-up visits after discharge from a psychiatric hospital admission (mean change in visits per month per psychiatrist 0.0099, 95% confidence interval [CI] -0.0989 to 0.1206; change in trend 0.0032, 95% CI -0.0035 to 0.0095) or after a suicide attempt (mean change -0.0910, 95% CI -0.1885 to 0.0026; change in trend 0.0102, 95% CI 0.0045 to 0.0159). There was also no change in the probability that patients received follow-up care after discharge (change in level -0.0079, 95% CI -0.0223 to 0.0061; change in trend 0.0007, 95% CI -0.0003 to 0.0016) or after a suicide attempt (change in level 0.0074, 95% CI -0.0094 to 0.0366; change in trend 0.0006, 95% CI -0.0007 to 0.0022). INTERPRETATION Our results suggest that implementation of the incentives did not increase access to follow-up care for patients after discharge from a psychiatric hospital admission or after a suicide attempt, and the incentives had no effect on supply of psychiatric services. Further research to guide design and implementation of more effective incentives is warranted.
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Affiliation(s)
- David Rudoler
- Institute for Mental Health Policy Research (Rudoler, de Oliveira, Cheng, Kurdyak), Centre for Addiction and Mental Health; Mental Health and Addictions Research Program (Rudoler, de Oliveira, Cheng, Kurdyak), Institute for Clinical Evaluative Sciences; Department of Psychiatry, Faculty of Medicine (Kurdyak) and Institute of Health Policy, Management and Evaluation (Rudoler, de Oliveira, Cheng), University of Toronto, Toronto, Ont.
| | - Claire de Oliveira
- Institute for Mental Health Policy Research (Rudoler, de Oliveira, Cheng, Kurdyak), Centre for Addiction and Mental Health; Mental Health and Addictions Research Program (Rudoler, de Oliveira, Cheng, Kurdyak), Institute for Clinical Evaluative Sciences; Department of Psychiatry, Faculty of Medicine (Kurdyak) and Institute of Health Policy, Management and Evaluation (Rudoler, de Oliveira, Cheng), University of Toronto, Toronto, Ont
| | - Joyce Cheng
- Institute for Mental Health Policy Research (Rudoler, de Oliveira, Cheng, Kurdyak), Centre for Addiction and Mental Health; Mental Health and Addictions Research Program (Rudoler, de Oliveira, Cheng, Kurdyak), Institute for Clinical Evaluative Sciences; Department of Psychiatry, Faculty of Medicine (Kurdyak) and Institute of Health Policy, Management and Evaluation (Rudoler, de Oliveira, Cheng), University of Toronto, Toronto, Ont
| | - Paul Kurdyak
- Institute for Mental Health Policy Research (Rudoler, de Oliveira, Cheng, Kurdyak), Centre for Addiction and Mental Health; Mental Health and Addictions Research Program (Rudoler, de Oliveira, Cheng, Kurdyak), Institute for Clinical Evaluative Sciences; Department of Psychiatry, Faculty of Medicine (Kurdyak) and Institute of Health Policy, Management and Evaluation (Rudoler, de Oliveira, Cheng), University of Toronto, Toronto, Ont
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Bermúdez-Tamayo C, Fernández Ruiz E, Pastor Moreno G, Maroto-Navarro G, Garcia-Mochon L, Perez-Ramos FJ, Caño-Aguilar A, Velez MDP. Barriers and enablers in the implementation of a program to reduce cesarean deliveries. Reprod Health 2017; 14:106. [PMID: 28851394 PMCID: PMC5576238 DOI: 10.1186/s12978-017-0369-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 08/16/2017] [Indexed: 11/17/2022] Open
Affiliation(s)
- Clara Bermúdez-Tamayo
- Andalusian School of Public Health, Cuesta del Observatorio 4 s/n, 18010, Granada, Spain. .,CIBERESP, Ciber de Epidemiologia y Salud Publica, Madrid, Spain.
| | | | | | - Gracia Maroto-Navarro
- Andalusian School of Public Health, Cuesta del Observatorio 4 s/n, 18010, Granada, Spain.,CIBERESP, Ciber de Epidemiologia y Salud Publica, Madrid, Spain
| | - Leticia Garcia-Mochon
- Andalusian School of Public Health, Cuesta del Observatorio 4 s/n, 18010, Granada, Spain
| | - Francisco Jose Perez-Ramos
- Consejería de Igualdad, Salud y Políticas Sociales, Junta de Andalucía, Sevilla, Avd. De Hytasa n° 14, 41006, Sevilla, Spain
| | - Africa Caño-Aguilar
- UGC Obstetrics and Gynaecology Hospital Universitario San Cecilio, Av Doctor Oloriz, 16, 18012, Granada, Spain
| | - Maria Del Pilar Velez
- Department of Obstetrics and Gynecology, Kingston General Hospital, Queen's University, Kingston, Canada
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Affiliation(s)
- Maurice McGregor
- Professor Emeritus of Medicine, McGill University, Montréal, Que
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Affiliation(s)
- Tara Kiran
- Department of Family and Community Medicine, St. Michael's Hospital, University of Toronto, and Centre for Urban Health Solutions, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ont.
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