Barriers and Facilitators to Health-Care Provider Payment Reform - A Scoping Literature Review

Background

Changes to provider payment systems are among the most common reforms in health care. They are important levers for policymakers to influence the health system performance. The aim of this study was to identify, systematize, and map the existing literature on the factors that influence health-care provider payment reforms.

Methods

A scoping review was conducted. Literature published in English between 2000 and 2022 was systematically searched in five databases, relevant organizations, and journals. Academic publications and grey literature on health-care provider payment reform and the factors influencing reform were considered. An inductive thematic analysis was applied to map the barriers and facilitators that influence payment reforms.

Results

The study included 51 publications. They were divided into four categories: empirical studies (n=17), literature reviews (n=6), discussion/policy papers (n=18), and technical reports/policy briefs (n=9). Most of the studies were conducted in developed economy countries (n=36). The most frequently reformed payment method was fee-for-service (n=37), and the newly implemented methods included bundled payments (n=16), pay-for-performance (n=15), and diagnosis-related groups (n=11). This study identified 43 sub-themes on barriers to provider payment reforms, which were grouped into eight main themes. It identified 51 sub-themes on facilitators, which were grouped into six themes. Barriers include stakeholder opposition, challenges related to reform design, hurdles in implementation structures, insufficient resources, challenges related to market structures, legal barriers, knowledge and information gaps, and negative publicity. Facilitators include stakeholder involvement, complementary reforms/policies, relevant prior experience, good leadership and management of change, sufficient resources, and external pressure to introduce reform.

Conclusion

The factors that influence health-care payment reforms are often contextual and interrelated, and encompass a variety of perspectives, including those of patients, providers, insurers, and policymakers. When planning reforms, one should anticipate potential barriers and devise appropriate interventions.

Registration

The study was registered with the Open Science Framework.

Incentive schemes to increase dementia diagnoses in primary care in England: a retrospective cohort study of unintended consequences

BACKGROUND

The UK government introduced two financial incentive schemes for primary care to tackle underdiagnosis in dementia: the 3-year Directed Enhanced Service 18 (DES18) and the 6-month Dementia Identification Scheme (DIS). The schemes appear to have been effective in boosting dementia diagnosis rates, but their unintended effects are unknown.

AIM

To identify and quantify unintended consequences associated with the DES18 and DIS schemes.

DESIGN AND SETTING

A retrospective cohort quantitative study of 7079 English primary care practices.

METHOD

Potential unintended effects of financial incentive schemes, both positive and negative, were identified from a literature review. A practice-level dataset covering the period 2006/2007 to 2015/2016 was constructed. Difference-in-differences analysis was employed to test the effects of the incentive schemes on quality measures from the Quality and Outcomes Framework (QOF); and four measures of patient experience from the GP Patient Survey (GPPS): patient-centred care, access to care, continuity of care, and the doctor-patient relationship. The researchers controlled for effects of the contemporaneous hospital incentive scheme for dementia and for practice characteristics.

RESULTS

National practice participation rates in DES18 and DIS were 98.5% and 76% respectively. Both schemes were associated not only with a positive impact on QOF quality outcomes, but also with negative impacts on some patient experience indicators.

CONCLUSION

The primary care incentive schemes for dementia appear to have enhanced QOF performance for the dementia review, and have had beneficial spillover effects on QOF performance in other clinical areas. However, the schemes may have had negative impacts on several aspects of patient experience.

Pay-for-performance: impact on diabetes

Pay-for-performance schemes explicitly link provider remuneration to the quality of care provided, with the aims of modifying provider behavior and improving patient outcomes. If successful, pay-for-performance schemes could drive improvements in quality and efficiency of care. However, financial incentives could also erode providers' intrinsic motivation, narrow their focus, promote unethical behavior, and ultimately increase health care inequalities. Evidence from schemes implemented to date suggests that carefully designed pay-for-performance schemes that align sufficient rewards with clinical priorities can produce modest but significant improvements in processes of diabetic care and intermediate outcomes. There is limited evidence, however, on whether improvements in processes of care result in improved outcomes, in terms of patient satisfaction, reduced complications, and greater longevity. The lack of adequate control groups has limited research findings to date, and more robust studies are needed to explore both the potential long-term benefits of pay-for-performance schemes and their unintended consequences.

A formative evaluation of a pay-for-performance system

Orientation: Pay-for-performance (PFP) systems emerged during the 1980s as performance improvement tools. However, research findings have shown contradictory evidence as to whether these systems motivate employees to improve their performance. Research purpose: The main aim of this evaluation was to assess whether a PFP system, which a South African university introduced for administrative employees, improved their performance. A secondary aim was to examine whether the university implemented the system as it intended to.Motivation for the evaluation: The motivation for this evaluation was to add to the social science literature on the effectiveness of PFP systems. There are many contradictions in the literature and further exploration of whether these systems deliver their intended outcomes seemed overdue.Research design, approach and method: The evaluators used a descriptive design. They administered a customised questionnaire, to which 391 university staff members responded. Of these, 129 were line managers and 262 were administrative staff.Main findings: The administrative staff, whose working lives the PFP system affected, thought that it did not improve their performance. Both line managers and administrative staff indicated that the pay aspect of the system did not differentiate between poor and excellent performance.Practical/managerial implications: The evaluators made practical recommendations for improving the implementation of the system.Contribution/value-add: This evaluation contributed to the social science literature on the effectiveness of PFP systems by showing that poor implementation rather than poor design often lies at the root of a system that does not deliver its intended outcomes.

Pay-for-virtue: an option to improve pay-for-performance?

Pay-for-performance schemes reward standardized professional behaviours associated with effective care. However, they neglect the significance of virtue and devalue and erode professional motivation based on virtue. Pay for training to cultivate virtue, and/or pay-for-virtue, may mitigate these dangers. Although virtue is typically considered its own reward, and the assessment of virtue is problematic, pay-for-virtue could involve (1) stringent checks on the appropriateness of the standardized care currently rewarded by pay-for-performance for individual patients or (2) pay for indicators of virtue. These indicators could be based on virtues identified from a framework of universal virtues and through logical inferences from features of practice. It is possible that pay-for-virtue could ultimately strengthen health professionals' intrinsic motivation for good practice, but this and the broader effects of pay-for-virtue would need careful investigation.

Does better disease management in primary care reduce hospital costs? Evidence from English primary care

We apply cross-sectional and panel data methods to a database of 5 million patients in 8000 English general practices to examine whether better primary care management of 10 chronic diseases is associated with reduced hospital costs. We find that only primary care performance in stroke care is associated with lower hospital costs. Our results suggest that the 10% improvement in the general practice quality of stroke care between 2004/5 and 2007/8 reduced 2007/8 hospital expenditure by about £130 million in England. The cost savings are due mainly to reductions in emergency admissions and outpatient visits, rather than to lower costs for patients treated in hospital or to reductions in elective admissions.

Does higher quality of diabetes management in family practice reduce unplanned hospital admissions?

OBJECTIVE

To investigate the association between indicators of quality of diabetic management in English family practices and emergency hospital admissions for short-term complications of diabetes.

STUDY SETTING

A total of 8,223 English family practices from 2001/2002 to 2006/2007.

STUDY DESIGN

Multiple regression analyses of associations between admissions and proportions of practice diabetic patients with good (glycated hemoglobin [HbA1c] ≤7.4 percent) and moderate (7.4 percent <HbA1c ≤10 percent) glycemic control. Covariates included diabetes prevalence, baseline admission rates, socioeconomic, demographic, and geographic characteristics.

DATA

Practice quality measures extracted from practice records linked with practice-level hospital admissions data and practice-level covariates data.

PRINCIPAL FINDINGS

Practices with 1 percent more patients with moderate rather than poor glycemic control on average had 1.9 percent (95 percent CI: 1.1-2.6 percent) lower rates of emergency admissions for acute hyperglycemic complications. Having more patients with good rather than moderate control was not associated with lower admissions. There was no association of moderate or good control with hypoglycemic admissions.

CONCLUSION

Cross-sectionally, family practices with better quality of diabetes care had fewer emergency admissions for short-term complications of diabetes. Over time, after controlling for national trends in admissions, improvements in quality in a family practice were associated with a reduction in its admissions.