Financial incentives and health provider behaviour: Evidence from a capitation policy in Ghana.

The capitation payment model has been used as a supply-side cost-containment tool in controlling physician behaviour. However, little is known regarding its effectiveness in controlling costs and discouraging use of low-value care. This study seeks to examine whether financial incentives in capitation influence provider behaviour, and if so, whether such behaviour compromises outcomes for inpatients with hypertension. To this end, we evaluate the effect on outpatient visits and inpatient outcomes of the introduction of capitation into a mixed payment system involving diagnosis-related groups and fee-for-service in the Ashanti region of Ghana. We use difference-in-differences with fixed effects and event study analysis of claims data over 48 months (2016-2019). We found that providers responded to financial incentives in capitation; outpatient visits were approximately 35% lower. However, we found no significant impact of capitation on inpatient outcomes; that is, the in-hospital death rate did not increase, and the length of hospital stay (which may be a rough indicator of the severity of illness) also did not increase. These findings indicate that patient health outcomes did not deteriorate. Evidence suggests that the observed reduction in outpatient visits may be in unnecessary or low-value visits, especially at lower levels of the healthcare system.

Impact of capitation on physicians' behavior among patients with hypertension: an interrupted time series study in rural China.

OBJECTIVE: The purpose of this study is to explore the change in physicians' hypertension treatment behavior before and after the reform of the capitation in county medical community. METHODS: Spanning from January 2014 to December 2019, monthly data of outpatient and inpatient were gathered before and after the implementation of the reform in April 2015. We employed interrupted time series analysis method to scrutinize the instantaneous level and slope changes in the indicators associated with physicians' behavior. RESULTS: Several indicators related to physicians' behavior demonstrated enhancement. After the reform, medical cost per visit for inpatient exhibited a reverse trajectory (-53.545, 95%CI: -78.620 to -28.470, p < 0.01). The rate of change in outpatient drug combination decelerated (0.320, 95%CI: 0.149 to 0.491, p < 0.01). The ratio of infusion declined for both outpatient and inpatient cases (-0.107, 95%CI: -0.209 to -0.004, p < 0.1; -0.843, 95%CI: -1.154 to -0.532, p < 0.01). However, the results revealed that overall medical cost per visit and drug proportion for outpatient care continued their initial upward trend. After the reform, the decline of drug proportion for outpatient care was less pronounced compared to the period prior to the reform, and length of stay also had a similar trend. CONCLUSION: To some extent, capitation under the county medical community encourages physicians to control the cost and adopt a more standardized diagnosis and treatment behavior. This study provides evidence to consider the impact of policy changes on physicians' behavior when designing payment methods and healthcare systems aimed at promoting PHC.

Increasing capitation in mixed remuneration schemes: Effects on service provision and process quality of care.

Many health systems apply mixed remuneration schemes for general practitioners, but little is known about the effects on service provision of changing the relative mix of fee for services and capitation. We apply difference-in-differences analyses to evaluate a reform that effectively reversed the mix between fee for services and capitation from 80/20 to 20/80 for patients with type 2 diabetes. Our results show reductions in provision of both the contact services that became capitated and in other non-capitated (still-billable) services. Reduced provision also occurred for guideline-recommended process quality services. We find that the effects are mainly driven by patients with co-morbidities and by general practitioners with high income, relatively many diabetes patients, and solo practitioners. Thus, increasing capitation in a mixed remuneration schemes appears to reduce service provision for patients with type 2 diabetes monitored in general practice with a risk of unwanted quality effects.

The effect of internal salary incentives based on insurance payment on physicians' behavior: experimental evidence.

BACKGROUND: Understanding how physicians respond to payment methods is crucial for designing effective incentives and enhancing the insurance system. Previous theoretical research has explored the effects of payment methods on physician behavior based on a two-level incentive path; however, empirical evidence to validate these theoretical frameworks is lacking. To address this research gap, we conducted a laboratory experiment to investigate physicians' behavioral responses to three types of internal salary incentives based on diagnosis-related-group (DRG) and fee-for-service (FFS). METHODS: A total of 150 medical students from Capital Medical University were recruited as participants. These subjects played the role of physicians in choosing the quantity of medical services for nine types of patients under three types of salary incentives-fixed wage, constant fixed wage with variable performance wage, and variable fixed wage with variable performance wage, of which performance wage referred to the payment method balance under FFS or DRG. We collected data on the quantities of medical services provided by the participants and analyzed the results using the Friedman test and the fixed effects model. RESULTS: The results showed that a fixed wage level did not have a significant impact on physicians' behavior. However, the patients benefited more under the fixed wage compared to other salary incentives. In the case of a floating wage system, which consisted of a constant fixed wage and a variable performance wage from the payment method balance, an increase in performance wage led to a decrease in physicians' service provision under DRG but an increase under FFS. Consequently, this resulted in a decrease in patient benefit. When the salary level remained constant, but the composition of the salary varied, physicians' behavior changed slightly under FFS but not significantly under DRG. Additionally, patient benefits decreased as the ratio of performance wages increased under FFS. CONCLUSIONS: While using payment method balance as physicians' salary may be effective in transferring incentives of payment methods to physicians through internal compensation frameworks, it should be used with caution, particularly when the measurement standard of care is imperfect.

How the Gender Wage Gap for Primary Care Physicians Differs by Compensation Approach : A Microsimulation Study.

BACKGROUND: The physician gender wage gap may be due, in part, to productivity-based compensation models that undervalue female practice patterns. OBJECTIVE: To determine how primary care physician (PCP) compensation by gender differs when applying existing productivity-based and alternative compensation models. DESIGN: Microsimulation. SETTING: 2016 to 2019 national clinical registry of 1222 primary care practices. PARTICIPANTS: Male and female PCPs matched on specialty, years since medical school graduation, practice site, and sessions worked. MEASUREMENTS: Net annual, full-time-equivalent compensation for male versus female PCPs, under productivity-based fee-for-service, panel size-based capitation without or with risk adjustment, and hybrid payment models. Microsimulation inputs included patient and visit characteristics and overhead expenses. RESULTS: Among 1435 matched male (n = 881) and female (n = 554) PCPs, female PCP panels included patients who were, on average, younger, had lower diagnosis-based risk scores, were more often female, and were more often uninsured or insured by Medicaid rather than by Medicare. Under productivity-based payment, female PCPs earned a median of $58 829 (interquartile range [IQR], $39 553 to $120 353; 21%) less than male PCPs. This gap was similar under capitation ($58 723 [IQR, $42 141 to $140 192]). It was larger under capitation risk-adjusted for age alone ($74 695 [IQR, $42 884 to $152 423]), for diagnosis-based scores alone ($114 792 [IQR, $49 080 to $215 326] and $89 974 [IQR, $26 175 to $173 760]), and for age-, sex-, and diagnosis-based scores ($83 438 [IQR, $28 927 to $129 414] and $66 195 [IQR, $11 899 to $96 566]). The gap was smaller and nonsignificant under capitation risk-adjusted for age and sex ($36 631 [IQR, $12 743 to $73 898]). LIMITATION: Panel attribution based on office visits. CONCLUSION: The gender wage gap varied by compensation model, with capitation risk-adjusted for patient age and sex resulting in a smaller gap. Future models might better align with primary care effort and outcomes. PRIMARY FUNDING SOURCE: None.

[Summary Community Health Centers in Belgium: thinking health out of the box]. / Les maisons médicales en Belgique : la santé dans tous ses états.

The federation of community health centersa includes 130 practices in French-speaking Belgium. They are organized as self-managed practices, which enables a certain equality between the workers in the team in terms of shared decision. Moreover, these care structures are organized as multidisciplinary teams and most of the time choose a capitation-fee payment for their services. This method of remuneration makes it possible to increase proactivity and improve prevention and health promotion, which are at the heart of the challenges for primary care. The center in Trooz illustrates this organization around the concept of community health. The active participation of patients in the project is at the center of the concerns to achieve patient-centered care.

La Fédération des maisons médicales (FMM) regroupe 130 pratiques en Belgique francophone. Elles sont organisées en autogestion, ce qui confère une certaine égalité entre les travailleurs de l'équipe quant aux décisions prises. Par ailleurs, ces structures de soins sont organisées en pratique multidisciplinaire et optent, la plupart du temps, pour un paiement forfaitaire de leurs prestations. Ce mode de rémunération permet d'augmenter la proactivité et d'améliorer la prévention et la promotion à la santé qui sont au cœur des défis de la première ligne. La maison médicale de Trooz illustre cette organisation autour du concept central de la santé communautaire. La participation active des patients dans le projet est au cœur des préoccupations pour réaliser une réelle approche centrée sur leurs besoins.

Capitated versus fee-for-service reimbursement and quality of care for chronic disease: a US cross-sectional analysis.

BACKGROUND: Upcoming alternative payment models Primary Care First (PCF) and Kidney Care Choices (KCC) incorporate capitated payments for chronic disease management. Prior research on the effect of capitated payments on chronic disease management has shown mixed results. We assessed the patient, physician, and practice characteristics of practices with capitation as the majority of revenue, and evaluated the association of capitated reimbursement with quality of chronic disease care. METHODS: We performed a cross-sectional analysis of visits in the United States' National Ambulatory Medical Care Survey (NAMCS) for patients with hypertension, diabetes, or chronic kidney disease (CKD). Our predictor was practice reimbursement type, classified as 1) majority capitation, 2) majority FFS, or 3) other reimbursement mix. Outcomes were quality indicators of hypertension control, diabetes control, angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (ACEi/ARB) use, and statin use. RESULTS: About 9% of visits were to practices with majority capitation revenue. Capitated practices, compared with FFS and other practices, had lower visit frequency (3.7 vs. 5.2 vs. 5.2, p = 0.006), were more likely to be located in the West Census Region (55% vs. 18% vs. 17%, p < 0.001), less likely to be solo practice (21% vs. 37% vs. 35%, p = 0.005), more likely to be owned by an insurance company, health plan or HMO (24% vs. 13% vs. 13%, p = 0.033), and more likely to have private insurance (43% vs. 25% vs. 19%, p = 0.004) and managed care payments (69% vs. 23% vs. 26%, p < 0.001) as the majority of revenue. The prevalence of controlled hypertension, controlled diabetes, ACEi/ARB use, and statin use was suboptimal across practice reimbursement types. Capitated reimbursement was not associated with differences in hypertension, diabetes, or CKD quality indicators, in multivariable models adjusting for patient, physician, and practice characteristics. CONCLUSIONS: Practices with majority capitation revenue differed substantially from FFS and other practices in patient, physician, and practice characteristics, but were not associated with consistent quality differences. Our findings establish baseline estimates of chronic disease quality of care performance by practice reimbursement composition, informing chronic disease care delivery within upcoming payment models.

Primary care physician payment mechanisms toward universal health coverage: A study of Iran and selected countries.

BACKGROUND AND AIM: Primary care physician (PCP) payment mechanisms can be important tools for addressing issues of access, quality, and equity in health care. The purpose of the present study is to compare the PCP payment mechanisms of Iran, Canada, Australia, New Zealand, England, Sweden, Norway, Denmark, the Netherlands, Turkey, and Thailand. METHODS: This is a descriptive-comparative study comparing the PCP payment mechanisms of Iran and selected countries in 2020. Data for each country are collected from reliable databases and are tabulated to compare their payment models. Framework analysis is used for data analysis. RESULTS: The results are provided in terms of PCP payment mechanisms, adjusting factor for capitation, reasons for fee-for-service payment, the role of pay-for-performance (PFP) programme, domain and indicators, and reasons for developing PFP in each country. CONCLUSION: The majority of the countries with high UHC service coverage index have applied a mix of PCP payment mechanisms, most of which include capitation and PFP. Moreover, adjusting capitation by factors such as age, sex, and health status will lead to provision of better services to high-risk populations. In recent years, PFP has been paid to Iranian PCPs in addition to salary. Given the various existing models for primary health care in Iran and the increasing burden of chronic diseases, a more appropriate combination of payment mechanisms that create more incentives to provide active and high-quality care should be developed. Also, when developing payment mechanisms, the required infrastructure such as electronic health record should be considered.

Payment methods for healthcare providers working in outpatient healthcare settings.

BACKGROUND: Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as 'out of hospital' care including primary care, are important for health systems in reducing the use of more expensive hospital services. OBJECTIVES: To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification. SELECTION CRITERIA: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes. MAIN RESULTS: We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies. AUTHORS' CONCLUSIONS: For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.

Twelve years with a capitation payment system in Swedish dental care: longitudinal development of oral health.

BACKGROUND: Since 2007, patients receiving oral health care within the Public Dental Service in Sweden have had the possibility to choose between the traditional fee-for-service (FFS) payment system or the new capitation payment system, 'Dental Care for Health' (DCH). Payment models are believed to involve different incentive structures for patients and caregivers. In theory, different incentives may lead to differences in health-related outcomes, and the research has been inconclusive. This 12-year longitudinal prospective cohort study of patients in regular dental care analyzes oral health development and self-reported oral health in relation to the patients' level of education in the two payment systems, and compares with the results from an earlier 6-year follow-up. METHODS: Information was obtained through a questionnaire and from a register from n = 5877 individuals who kept their original choice of payment model for 12 years, 1650 patients in DCH and 4227 in FFS, in the Public Dental Service in Region Västra Götaland, Sweden. The data comprised manifest caries prevalence, levels of self-reported oral health and education, and choice of dental care payment model. Analyses were performed with chi square and multivariable regression analysis. RESULTS: The findings from the 6-year follow-up were essentially maintained at the 12-year examination, showing that the pre-baseline caries prevalence is the most influential factor for less favorable oral health development in terms of the resulting caries prevalence. Educational level (≥ university) showed an increased influence on the risk of higher caries prevalence after 12 years and differed between payment models with regard to the relation to self-rated oral health. CONCLUSIONS: Differences in health and health-influencing properties between payment models were sustained from 6 to 12 years. Strategies for making use of potential compensatory mechanisms within the capitation payment system to increase oral health equality should be considered.

Adult capped dental payment model applied within a university setting: an Australian reflective case study.

BACKGROUND: Capitation models of care in dentistry started around 1973 with varying degrees of success in meeting the needs of the individuals and expectations of the participating private practitioners. These studies mostly identified that capitation payments resulted in under treatment whilst fee-for-service models often led to over treatment. The objective of this study was to develop a new way of doing business using an outsourcing capitation model of care to meet population health needs and activity-based funding requirements of rural Local Health Districts with a local university dental school. This payment model is an alternate referral pathway for public oral health practitioners from the existing New South Wales Oral Health Fee-for-Service Scheme that focuses on urgent treatment to one that offers an all-inclusive preventive approach that concentrates on sustaining good long-term oral health for the individual. METHOD: The reflective study analysed various adult age cohorts (18-24, 25-34, 35-44, 45-54, 55-64, 65-74 and 75 + years) based on 950 participants randomly selected from the Greater Southern adult public dental waiting lists. The study's capitation formula was derived from NSW government adult treatment items (n = 447,625). Dental care was provided through the local university's dental clinics utilising only dental students under clinical supervision. All data were sourced from NSW Oral Health Data Warehouse during 1 January 2012-30 June 2018 and analysed by using SAS 9.3 and Version 13 Microsoft Excel. RESULTS: There were 10,305 dental care items and 1129 capitation courses of care totalling A$599,026. This resulted in an average of 11 dental care items being provided to each participant. The capitation payment formula utilising the most provided dental care items of 100 individual patients proved to be economical and preventive focused. CONCLUSION: The systematic reflection showed that this unique methodology in developing an adult capitation payment formula associated to diagnostic pathways that resulted in: (i) more efficient usage of government expenditure on public dental services, (ii) provision of person-centred courses of dental care, and (iii) utilisation of university dental education programs to best practice treatment and holistic care.

Mental Health Services Provision in Primary Care and Emergency Department Settings: Analysis of Blended Fee-for-Service and Blended Capitation Models in Ontario, Canada.

Treating mental illnesses in primary care is increasingly emphasized to improve access to mental health services. Although family physicians (FPs) or general practitioners are in an ideal position to provide the bulk of mental health care, it is unclear how best to remunerate FPs for the adequate provision of mental health services. We examined the quantity of mental health services provided in Ontario's blended fee-for-service and blended capitation models. We evaluated the impact of FPs switching from blended fee-for-service to blended capitation on the provision of mental health services in primary care and emergency department using longitudinal health administrative data from 2007 to 2016. We accounted for the differences between those who switched to blended capitation and non-switchers in the baseline using propensity score weighted fixed-effects regressions to compare remuneration models. We found that switching from blended fee-for-service to blended capitation was associated with a 14% decrease (95% CI 12-14%) in the number of mental health services and an 18% decrease (95% CI 15-20%) in the corresponding value of services. This result was driven by the decrease in services during regular-hours. During after-hours, the number of services increased by 20% (95% CI 10-32%) and the corresponding value increased by 35% (95% CI 17-54%). Switching was associated with a 4% (95% CI 1-8%) decrease in emergency department visits for mental health reasons. Blended capitation reduced provision of mental health services without increasing emergency department visits, suggesting potential efficiency gain in the blended capitation model in Ontario.

Stirring the pot: Switching from blended fee-for-service to blended capitation models of physician remuneration.

In Canada's most populous province, Ontario, family physicians may choose between the blended fee-for-service (Family Health Group [FHG]) and blended capitation (Family Health Organization [FHO] payment models). Both models incentivize physicians to provide after-hours (AH) and comprehensive care, but FHO physicians receive a capitation payment per enrolled patient adjusted for age and sex, plus a reduced fee-for-service while FHG physicians are paid by fee-for-service. We develop a theoretical model of physician labor supply with multitasking to predict their behavior under FHG and FHO, and estimable equations are derived to test the predictions empirically. Using health administrative data from 2006 to 2014 and a two-stage estimation strategy, we study the impact of switching from FHG to FHO on the production of a capitated basket of services, after-hours services and nonincentivized services. Our results reveal that switching from the FHG to FHO reduces the production of capitated services to enrolled patients and services to nonenrolled patients by 15% and 5% per annum and increases the production of after-hours and nonincentivized services by 8% and 15% per annum.

Putting Providers At-Risk through Capitation or Shared Savings: How Strong are Incentives for Upcoding and Treatment Changes?

BACKGROUND: Alternative payment models, including Accountable Care Organizations and fully capitated models, change incentives for treatment over fee-for-service models and are widely used in a variety of settings. The level of payment may affect the assignment to a payment category, but to date the upcoding literature has been motivated largely incorporating financial penalties for upcoding rather than by a theoretical model that incorporates the downstream effects of upcoding on service provision requirements. AIMS OF THE STUDY: In this paper, we contribute to the literature on upcoding by developing a new theoretical model that is applicable to capitated, case-rate and shared savings payment systems. This model incorporates the downstream effects of upcoding on service provision requirements rather than just the avoidance of penalties. This difference is important especially for shared-savings models with quality benchmarks. METHODS: We test implications of our theoretical model on changes in severity determination and service use associated with changes in case-rate payments in a publicly-funded mental health care system. We model provider-assigned severity categories as a function of risk-adjusted capitated payments using conditional logit regressions and counts of service days per month using negative binomial models. RESULTS: We find that severity determination is only weakly associated with the payment rate, with relatively small upcoding effects, but that level of use shows a greater degree of association. DISCUSSION: These results are consistent with our theoretical predictions where the marginal utility of savings or profit is small, as would be expected from public sector agencies. Upcoding did seem to occur, but at very small levels and may have been mitigated after the county and providers had some experience with the new system. The association between the payment levels and the number of service days in a month, however, was significant in the first period, and potentially at a clinically important level. Limitations include data from a single county/multiple provider system and potential unmeasured confounding during the post-implementation period. IMPLICATIONS FOR HEALTH CARE PROVISION AND USE: Providers in our data were not at risk for inpatient services but decreases in use of outpatient services associated with rate decreases may lead to further increases in inpatient use and therefore expenditures over time. IMPLICATIONS FOR HEALTH POLICIES: Health program directors and policy makers need to be acutely aware of the interplay between provider payments and patient care and eventual health and mental health outcomes. IMPLICATIONS FOR FURTHER RESEARCH: Further research could examine the implications of the theoretical model of upcoding in other payment systems, estimate the power of the tiered-risk systems, and examine their influence on clinical outcomes.

Payment models in primary health care: A driver of the quantity and quality of medical laboratory utilization.

Physician payment models' incentives regarding many aspects of primary health care are not well understood. We focus on the case of medical laboratory utilization and examine how physicians' laboratory test ordering patterns change following a switch to a blended capitation payment model from one with fee for service enhanced with pay for performance. Also, within blended capitation, we examine differences between traditional staffing and interdisciplinary teams. Using a propensity score weighted fixed-effects specification to address selection, it is estimated that the switch to capitation leads to a short-run average of 3% fewer laboratory requisitions per patient. Patients' laboratory utilization also becomes more concentrated with the rostering physician. More importantly, using diabetes-related laboratory tests as a case study, after joining the blended model, physicians order 3% fewer inappropriate/redundant tests, and the addition of an interdisciplinary care team makes the reduction about 9%. Advances in both continuity and quality seem to be associated with blended capitation.

Responding to policy makers' evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso.

BACKGROUND: The last two decades have seen a growing recognition of the need to expand the impact evaluation toolbox from an exclusive focus on randomized controlled trials to including quasi-experimental approaches. This appears to be particularly relevant when evaluation complex health interventions embedded in real-life settings often characterized by multiple research interests, limited researcher control, concurrently implemented policies and interventions, and other internal validity-threatening circumstances. To date, however, most studies described in the literature have employed either an exclusive experimental or an exclusive quasi-experimental approach. METHODS: This paper presents the case of a study design exploiting the respective advantages of both approaches by combining experimental and quasi-experimental elements to evaluate the impact of a Performance-Based Financing (PBF) intervention in Burkina Faso. Specifically, the study employed a quasi-experimental design (pretest-posttest with comparison) with a nested experimental component (randomized controlled trial). A difference-in-differences approach was used as the main analytical strategy. DISCUSSION: We aim to illustrate a way to reconcile scientific and pragmatic concerns to generate policy-relevant evidence on the intervention's impact, which is methodologically rigorous in its identification strategy but also considerate of the context within which the intervention took place. In particular, we highlight how we formulated our research questions, ultimately leading our design choices, on the basis of the knowledge needs expressed by the policy and implementing stakeholders. We discuss methodological weaknesses of the design arising from contextual constraints and the accommodation of various interests, and how we worked ex-post to address them to the best extent possible to ensure maximal accuracy and credibility of our findings. We hope that our case may be inspirational for other researchers wishing to undertake research in settings where field circumstances do not appear to be ideal for an impact evaluation. TRIAL REGISTRATION: Registered with RIDIE (RIDIE-STUDY-ID- 54412a964bce8 ) on 10/17/2014.

Periodic health visits by primary care practice model, a population-based study using health administrative data.

BACKGROUND: The general health check, which includes the periodic health visit and annual physical exam, is not recommended to maintain the health of asymptomatic adults with no risk factors. Different funding mechanisms for primary care may be associated with the provision of service delivery according to recommended guidelines. We sought to determine how use of the periodic health visit for healthy individuals without comorbidities, despite evidence against its use, differed by primary care model. METHODS: Population-based cross-sectional study using linked health and administrative datasets in Ontario, Canada, where most residents are insured for physician services through Ontario's single payer, provincially funded Ontario Health Insurance Plan. Participants included all living adults (> 19 years) in Ontario on January 1st, 2014, eligible for the Ontario Health Insurance Plan. Primary care enrollment model was the main exposure and included traditional fee-for-service, enhanced fee-for-service, capitation, team-based care, other (including salaried), and unenrolled. The main outcome measure was receipt of a periodic health visit during 2014. Age-sex standardized rates of periodic health visits performed during the one-year study period were analyzed by number of comorbid conditions. RESULTS: Of 10,712,804 adults in Ontario, 2,350,386 (21.9%) had a periodic health visit in 2014. The age-sex standardized rate was 6.1% (95% confidence interval [CI] 6.0, 6.1%) for healthy individuals. In the traditional fee-for-service model, the periodic health visit was performed for 55.3% (95% CI 54.4, 56.3%) of healthy individuals versus 10.2% (95% CI 10.0, 10.3%) in team-based care. Periodic health visit rates varied by primary care provider models. Traditional and enhanced fee-for-service models had higher rates across all comorbidity groups. CONCLUSIONS: Patients whose primary care physicians are funded exclusively through fee-for-service had the highest rates of periodic health visits in healthy individuals. Primary care reform initiatives must consider the influence of remuneration on providing evidence-based primary care.

Health care purchasing in Kenya: Experiences of health care providers with capitation and fee-for-service provider payment mechanisms.

BACKGROUND: Provider payment mechanisms (PPMs) play a critical role in universal health coverage due to the incentives they create for health care providers to deliver needed services, quality, and efficiency. We set out to explore public, private, and faith-based providers' experiences with capitation and fee-for-service in Kenya and identified attributes of PPMs that providers considered important. METHODS: We conducted a qualitative study in two counties in Kenya. Data were collected using semistructured interviews with 29 management team members in six health providers accredited by the National Hospital Insurance Fund (NHIF). RESULTS: Capitation and fee-for-service payments from the NHIF and private insurers were reported as good revenue sources as they contributed to providers' overall income. The expected fee-for-service payment amounts from NHIF and private insurers were predictable while capitation funds from NHIF were not because providers did not have information on the number of enrolees in their capitation pool. Moreover, capitation payment rates were perceived as inadequate. Capitation and fee-for-service payments from NHIF and private insurers were disbursed late. Finally, public providers had lost their autonomy to access and utilise capitation and fee-for-service payments from the NHIF. CONCLUSION: Through their experiences, health care providers revealed characteristics of PPMs that they considered important.

Development of age-sex adjusted capitation payment: The experience of Iranian public health complexes.

BACKGROUND: Flat capitations are not necessarily able to compensate health providers equitably due to the variability of resource consumption among different age and sex groups. The aim of this study is to develop a risk adjusted capitation formula as a base for primary health care payment in Health Complexes of Tabriz, in Iran. METHOD: This cross-sectional study was conducted in four stages: (1) determining health service package, (2) calculating unit cost of services, (3) estimating service utilization, and (4) calculating age/sex weighted capitation. We calculated unit cost of services with and without building and equipment expenses. Data collection was carried out through a data extraction checklist. Data management and analysis was carried out via Microsoft Excel 2007. RESULT: A list of 99 services and their processes were identified and then assigned each to one of 10 categories according to their resource consumption. The lowest and highest unit cost, respectively, belonged to prenatal care and group training by family physicians. The risk adjusted capitation was calculated with and without renting cost of building and equipment, respectively, 347 000 and 332 000 Rials (1 US$ worth 35 000 Iranian Rials). CONCLUSION: The development of health risk adjusted capitation could improve equity in payment system and the efficiency of delivering primary health care services. Estimated weights proposed with our study can be adapted then applied in contexts with similar characteristics.