Impact of Team-Based Care on Emergency Department Use.

PURPOSE: We sought to assess the impact of team-based care on emergency department (ED) use in the context of physicians transitioning from fee-for-service payment to capitation payment in Ontario, Canada. METHODS: We conducted an interrupted time series analysis to assess annual ED visit rates before and after transition from an enhanced fee-for-service model to either a team capitation model or a nonteam capitation model. We included Ontario residents aged 19 years and older who had at least 3 years of outcome data both pretransition and post-transition (N = 2,524,124). We adjusted for age, sex, income quintile, immigration status, comorbidity, and morbidity, and we stratified by rurality. A sensitivity analysis compared outcomes for team vs nonteam patients matched on year of transition, age, sex, rurality, and health region. RESULTS: We compared 387,607 team and 1,399,103 nonteam patients in big cities, 213,394 team and 380,009 nonteam patients in small towns, and 65,289 team and 78,722 nonteam patients in rural areas. In big cities, after adjustment, the ED visit rate increased by 2.4% (95% CI, 2.2% to 2.6%) per year for team patients and 5.2% (95% CI, 5.1% to 5.3%) per year for nonteam patients in the years after transition (P <.001). Similarly, there was a slower increase in ED visits for team relative to nonteam patients in small towns (0.9% [95% CI, 0.7% to 1.1%] vs 2.9% [95% CI, 2.8% to 3.1%], P <.001) and rural areas (‒0.5% [95% CI, -0.8% to 0.2%] vs 1.3% [95% CI, 1.0% to 1.6%], P <.001). Results were much the same in the matched analysis. CONCLUSIONS: Adoption of team-based primary care may reduce ED use. Further research is needed to understand optimal team composition and roles.

[Financing of integrated health service networks]. / Financiamiento de redes integradas de servicios de salud.

The countries of Latin America and the Caribbean need to increase their public resources in health to expand equitable and efficient access to health. The increase should finance a specific model with proven effectiveness, such as integrated health service networks (IHSN) based on primary health care. The global literature has not paid sufficient attention to financing IHSN; rather, it has focused on isolated facilities and agents, as well as on specific mechanisms. However, in the Region of the Americas, their development has been a necessity for years. An IHSN is a group of health organizations that offers coordinated health interventions and services to a population under their charge and assumes health and economic responsibility for achieving better health outcomes. A system of payment to an IHSN should be aimed at promoting the integrality of care and encouraging a focus on the life cycle of individuals, the articulation and the coordination of services. The risk-adjusted population budget is a possible and powerful mechanism to support the achievement of the objectives. Its development requires the recognition that the type of financing alone will not respond to the challenges and that there is a need for both health planning and health management. The technical, political and institutional challenges need to be addressed to succeed in this effort, which in turn must be embedded in the overall process of transforming health systems towards universal health.

Effects of New Funding Models for Patient-Centered Medical Homes on Primary Care Practice Finances and Services: Results of a Microsimulation Model.

PURPOSE: We assess the financial implications for primary care practices of participating in patient-centered medical home (PCMH) funding initiatives. METHODS: We estimated practices' changes in net revenue under 3 PCMH funding initiatives: increased fee-for-service (FFS) payments, traditional FFS with additional per-member-per-month (PMPM) payments, or traditional FFS with PMPM and pay-for-performance (P4P) payments. Net revenue estimates were based on a validated microsimulation model utilizing national practice surveys. Simulated practices reflecting the national range of practice size, location, and patient population were examined under several potential changes in clinical services: investments in patient tracking, communications, and quality improvement; increased support staff; altered visit templates to accommodate longer visits, telephone visits or electronic visits; and extended service delivery hours. RESULTS: Under the status quo of traditional FFS payments, clinics operate near their maximum estimated possible net revenue levels, suggesting they respond strongly to existing financial incentives. Practices gained substantial additional net annual revenue per full-time physician under PMPM or PMPM plus P4P payments ($113,300 per year, 95% CI, $28,500 to $198,200) but not under increased FFS payments (-$53,500, 95% CI, -$69,700 to -$37,200), after accounting for costs of meeting PCMH funding requirements. Expanding services beyond minimum required levels decreased net revenue, because traditional FFS revenues decreased. CONCLUSIONS: PCMH funding through PMPM payments could substantially improve practice finances but will not offer sufficient financial incentives to expand services beyond minimum requirements for PCMH funding.

The impact of reimbursement systems on equity in access and quality of primary care: A systematic literature review.

BACKGROUND: Reimbursement systems provide incentives to health care providers and may drive physician behaviour. This review assesses the impact of reimbursement system on socioeconomic and racial inequalities in access, utilization and quality of primary care. METHODS: A systematic search was performed in Web of Science and PubMed for English language studies published between 1980 and 2013, supplemented by reference tracking. Articles were selected based on inclusion criteria, and data extraction and critical appraisal were performed by two authors independently. Data were synthesized in a narrative manner and categorized according to study outcome and reimbursement system. RESULTS: Twenty seven articles, mostly from the United States and United Kingdom, were included in the data synthesis. Reimbursement systems seem to have limited effect on socioeconomic and racial inequity in access, utilization and quality of primary care. Capitation might have a more beneficial impact on inequity in access to primary care and number of ambulatory care sensitive admissions than fee-for-service, but did worse in patient satisfaction. Pay-for-performance had little or no impact on socioeconomic and racial inequity in the management of diabetes, cardiovascular diseases, chronic obstructive pulmonary disease, and preventive services. CONCLUSION: We found little scientific evidence supporting an association between reimbursement system and socioeconomic or racial inequity in access, utilization and quality of primary care. Overall, few studies addressed this research question, and heterogeneity in context and outcomes complicates comparisons across studies. Further empirical studies are warranted.

Defining a risk-adjustment formula for the introduction of population-based payments for primary care in France.

Novel risk-adjusted payment models for financing primary care are currently being experimented in France. In particular, pilot schemes including shared-savings contracts or prospectively allocated capitation payments are implemented for voluntary primary care structures. Such payment mechanisms require defining a risk-adjustment formula to accurately estimate expected expenditure while maintaining appropriate efficiency incentives. We used nationwide data from the French national health data system (SNDS) to compare the performance of different prospective models for total and outpatient expenditure prediction among more than 8 million individuals aged 65 or more and their application at an aggregate level. We focused on the characterization of morbidity status and on the contextual characteristics to include in the formula. We proposed a set of practical routinely available predictors with fair performance for patient-level expenditure prediction (explaining 32% of variance) that could be used to risk-adjust prospective payments in the French setting. Morbidity information was the strongest predictor but could lead to considerable error in predicted expenditures if introduced as independent binary variables in multiplicative models, underlining the importance of summary morbidity measures and of using the appropriate metric to assess model performance. Distribution of aggregate-level allocations was greatly modified according to the method to account for contextual characteristics. Our work informs the introduction of risk-adjusted models in France and underlines efficiency and fairness issues raised.

Documenting New Ways of Delivering Care Under Oregon's Alternative Payment and Advanced Care Model.

BACKGROUND: The fee-for-service reimbursement system that dominates health care throughout the United States links payment to a billable office visit with a physician or advanced practice provider. Under Oregon's Alternative Payment and Advanced Care Model (APCM), initiated in 2013, participating community health centers (CHCs) received per-member-per-month payments for empaneled Medicaid patients in lieu of standard fee-for-service Medicaid payments. With Medicaid revenue under APCM no longer tied solely to the volume of visits, the Oregon Health Authority needed a way to document the full range of care and services that CHCs were providing to their patients, including nontraditional patient encounters taking place outside of traditional face-to-face visits with a billable provider. Toward this end, program leadership defined 18 visit and nonvisit-based care activities-"Care Services That Engage Patients" (Care STEPs)-that APCM CHCs were asked to document in the electronic health record to demonstrate continued empanelment. OBJECTIVE: To describe trends in rates of traditional face-to-face office visits and Care STEPs documentation among CHCs involved in the first 3 phases of APCM implementation. RESEARCH DESIGN: The study population included the 9 CHCs involved in the first 3 phases of APCM implementation. Using data from the electronic health record, quarterly summary rates for office visits and Care STEPs were calculated for the first 18 quarters of implementation (March 1, 2013 to June 30, 2017). RESULTS: Among participating CHCs, the mean rate of face-to-face visits with billable providers declined from 635 ± 128 to 461 ± 109 visits/1000 patients/quarter (mean difference, -174; 95% CI, -255, -94). Care STEPs documentation increased from 831 ± 174 to 1017 ± 369 Care Steps/1000 patients/quarter, but the difference was not statistically significant. Care STEPs within the category of New Visit Types were documented most frequently. There were significant increases in documentation of Patient Care Coordination and Integration and a small, albeit significant, increase in Reducing Barriers to Health. There was a significant decline in the documentation of Care STEPs by physicians and advanced practice providers an increase in documentation by ancillary staff. CONCLUSIONS: These findings suggest that APCM is increasing CHCs' capacity to experiment with new ways of providing care beyond the traditional face-to-face office visit with a physician or advanced practice provider. However, CHCs may choose different ways to change the delivery of care and some CHCs have implemented these changes more quickly than others. Future mixed-methods research is needed to understand barriers and facilitators to changing the delivery of care after APCM implementation.

Evaluation of a policy to strengthen case management and quality of diabetes care in general practice in Denmark.

OBJECTIVES: To evaluate the utilization of a policy for strengthening general practitioner's case management and quality of care of diabetes patients in Denmark incentivized by a novel payment mode. We also want to elucidate any geographical variation or variation on the basis of practice features such as solo- or group practice, size of practice and age of the GP. METHODS: On the basis registers encompassing reimbursement data from GPs and practice specific information about geographical location (region), type of practice (solo- or group-practice), size of practice (number of patients listed) and age of the GP were are able to determine differences in use of the policy in relation to the practice-specific information. RESULTS: At the end of the study period (2007-2012) approximately 30% of practices have enrolled extending services to approximately 10% of the diabetes population. There is regional--as well as organizational differences between GPs who have enrolled and the national averages with enrolees being younger, from larger practices and with more patients listed. CONCLUSIONS: Our study documents an organizationally and regionally varied and limited utilization with the overall incentive structure defined in the policy not strong enough to move the majority of GPs to change their way of delivering and financing care for patients with diabetes within a period of more than 5 years.

Novo financiamento para uma nova Atenção Primária à Saúde no Brasil / New funding for a new Brazilian Primary Health Care

Resumo O objetivo desse artigo é apresentar um debate sobre a nova política de financiamento para Atenção Primária à Saúde (APS) no Brasil. Para desenvolvimento do método de pagamento foi realizado consulta da literatura nacional e internacional, além do envolvimento de gestores municipais, estaduais e federais da APS. O modelo final proposto é baseado em Capitação ponderada; Pagamento por desempenho; Incentivo para Ações Estratégicas. A capitação é ponderada por vulnerabilidade socioeconômica, aspectos demográficos e ajuste municipal, o pagamento por desempenho composto por um conjunto total de 21 indicadores e incentivos a ações estratégicas foi possível a partir da manutenção de alguns programas específicos. Os resultados das simulações apontaram para um baixo cadastro (90 milhões de brasileiros) para a cobertura estimada atual (148.674.300 milhões de brasileiros). Além disso, demonstraram um incremento imediato de recursos financeiros para 4.200 municípios brasileiros. Observa-se que a proposta do financiamento traz a APS brasileira para o século XXI, aponta para o fortalecimento dos atributos da APS e torna concreto os princípios de universalidade e equidade do Sistema Único de Saúde.

Abstract This paper aims to present a debate on the new Brazilian Primary Health Care (PHC) funding policy. We consulted the national and international literature, and we involved municipal, state, and federal PHC managers to develop the payment method. The proposed final model is based on weighted capitation, payment-for-performance, and incentive for strategic actions. Capitation is weighted by the socioeconomic vulnerability, demographic aspects, and municipal adjustment, the payment-for-performance consists of an entire set of 21 indicators, and incentives for strategic actions were facilitated from the maintenance of some specific programs. The results of the simulations pointed to low registration (90 million Brazilians) for the currently estimated coverage (148,674,300 Brazilians). Moreover, they showed an immediate increase in financial resources for 4,200 Brazilian municipalities. We observed that the funding proposal brings Brazilian PHC into the 21st century, points to the strengthening of PHC attributes, and materializes the principles of universality and equity of the Unified Health System.

Capitated payments to primary care providers and the delivery of patient education.

INTRODUCTION: Patient education is a critical component of the patient-centered medical home and is a powerful and effective tool in chronic disease management. However, little is known about the effect of practice payment on rates of patient education during office encounters. METHODS: For this study we took data from the 2009 National Ambulatory Medical Care Survey. This was a cross-sectional analysis of patient visits to primary care providers to determine whether practice payment in the form of capitated payments is associated within patient education being included more frequently during office visits compared with other payment methods. RESULTS: In a sample size of 9863 visits in which capitation status was available and the provider was the patient's primary care provider, the weighted percentages of visits including patient education were measured as a percentages of education (95% confidence intervals): <25% capitation, 42.7% (38.3-47.3); 26% to 50% capitation, 37.6% (23.5-54.2); 51% to 75% capitation, 38.4% (28.1-49.8); >75% capitation, 74.0% (52.2-88.1). In an adjusted logistic model controlling for new patients (yes/no), number of chronic conditions, number of medications managed, number of previous visits within the year, and age and sex of the patients, the odds of receiving education were reported as odds ratios (95% confidence intervals): <25% capitation, 1.00 (1.00-1.00); 26% to 50% capitation, 0.77 (0.38-1.58); 51% to 75% capitation, 0.81 (0.53-1.25); and >75% capitation, 3.38 (1.23-9.30). CONCLUSIONS: Patients are more likely to receive education if their primary care providers receive primarily capitated payment. This association is generally important for health policymakers constructing payment strategies for patient populations who would most benefit from interventions that incorporate or depend on patient education, such as populations requiring management of chronic diseases.

La crisis hospitalaria: análisis de la producción y el pago por servicios individuales de salud en un hospital de primer nivel de atención de la red pública de Bogotá, Colombia / Hospital crisis: analysis of production and payment for individual health care services in a first level public hospital in bogotá

En diversos medios de información generales y especializados se ha vuelto a hablar recientemente de una crisis en la red pública hospitalaria de todo el país que también ha involucrado a los hospitales de Bogotá. Diversas causas se han atribuido a la mencionada crisis, entre las cuales figura la modalidad de contratación y el pago por venta de servicios a los distintos pagadores identificados en el sistema. Se presenta un análisis de la producción y la facturación por servicios individuales en una Empresa Social del Estado de primer nivel de atención durante el tercer trimestre de 2011, comparándola con su facturación si contratara mediante pago por evento según las tarifas del Seguro Obligatorio de Accidentes de Tránsito (SOAT). Se identifica una disminución en la facturación al Fondo Financiero Distrital de Salud y también en la facturación a las EPS cuando se plantea el ejercicio del pago por evento de los servicios producidos y facturados en el periodo analizado.

In various general and expertise media has recently revived talk of a crisis in the public hospital network across the country that has also involved the hospitals in Bogota city. Multiple causes have been attributed to the aforementioned crisis, among which is the type of contract and payment for the sale of services to different payers identified in the system. This case study presents an analysis of production and billing for individual services in a first level State Social Enterprise care, during the third quarter of 2011, compared with its turnover if pay-per-hire by the rates from Mandatory Traffic Accidents Insurance (SOAT). It identifies a lower level of billing to Financial District Health Fund (FFDS) and a lower level too in billing to the Subsidized Health Promoting Enterprises (EPSS) when exercise raises the event of payment for the services produced and billed in the analyzed period.