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.

A physician-led initiative to improve clinical documentation results in improved health care documentation, case mix index, and increased contribution margin.

INTRODUCTION: Clinical documentation is the key determinant of inpatient acuity of illness and payer reimbursement. Every inpatient hospitalization is placed into a diagnosis related group with a relative value based on documented procedures, conditions, comorbidities and complications. The Case Mix Index (CMI) is an average of these diagnosis related groups and directly impacts physician profiling, medical center profiling, reimbursement, and quality reporting. We hypothesize that a focused, physician-led initiative to improve clinical documentation of vascular surgery inpatients results in increased CMI and contribution margin. METHODS: A physician-led coding initiative to educate physicians on the documentation of comorbidities and conditions was initiated with concurrent chart review sessions with coding specialists for 3 months, and then as needed, after the creation of a vascular surgery documentation guide. Clinical documentation and billing for all carotid endarterectomy (CEA) and open infrainguinal procedures (OIPs) performed between January 2013 and July 2016 were stratified into precoding and postcoding initiative groups. Age, duration of stay, direct costs, actual reimbursements, contribution margin (CM), CMI, rate of complication or comorbidity, major complication or comorbidity, severity of illness, and risk of mortality assigned to each discharge were abstracted. Data were compared over time by standardizing Centers for Medicare and Medicaid Services (CMS) values for each diagnosis related group and using a CMS base rate reimbursement. RESULTS: Among 458 CEA admissions, postcoding initiative CEA patients (n = 253) had a significantly higher CMI (1.36 vs 1.25; P = .03), CM ($7859 vs $6650; P = .048), and CMS base rate reimbursement ($8955 vs $8258; P = .03) than precoding initiative CEA patients (n = 205). The proportion of admissions with a documented major complication or comorbidity and complication or comorbidity was significantly higher after the coding initiative (43% vs 27%; P < .01). Among 504 OIPs, postcoding initiative patients (n = 227) had a significantly higher CMI (2.23 vs 2.05; P < .01), actual reimbursement ($23,203 vs $19,909; P < .01), CM ($12,165 vs $8840; P < .01), and CMS base rate reimbursement ($14,649 vs $13,496; P < .01) than precoding initiative patients (n = 277). The proportion of admissions with a documented major complication or comorbidity and complication or comorbidity was significantly higher after the coding initiative (61% vs 43%; P < .01). For both CEA and OIPs, there were no differences in age, duration of stay, total direct costs, or primary insurance status between the precoding and postcoding patient groups. CONCLUSIONS: Accurate and detailed clinical documentation is required for key stakeholders to characterize the acuity of inpatient admissions and ensure appropriate reimbursement; it is also a key component of risk-adjustment methods for assessing quality of care. A physician-led documentation initiative significantly increased CMI and CM.

Comparison of primary care models in the prevention of cardiovascular disease - a cross sectional study.

BACKGROUND: Primary care providers play an important role in preventing and managing cardiovascular disease. This study compared the quality of preventive cardiovascular care delivery amongst different primary care models. METHODS: This is a secondary analysis of a larger randomized control trial, known as the Improved Delivery of Cardiovascular Care (IDOCC) through Outreach Facilitation. Using baseline data collected through IDOCC, we conducted a cross-sectional study of 82 primary care practices from three delivery models in Eastern Ontario, Canada: 43 fee-for-service, 27 blended-capitation and 12 community health centres with salary-based physicians. Medical chart audits from 4,808 patients with or at high risk of developing cardiovascular disease were used to examine each practice's adherence to ten evidence-based processes of care for diabetes, chronic kidney disease, dyslipidemia, hypertension, weight management, and smoking cessation care. Generalized estimating equation models adjusting for age, sex, rurality, number of cardiovascular-related comorbidities, and year of data collection were used to compare guideline adherence amongst the three models. RESULTS: The percentage of patients with diabetes that received two hemoglobin A1c tests during the study year was significantly higher in community health centres (69%) than in fee-for-service (45%) practices (Adjusted Odds Ratio (AOR) = 2.4 [95% CI 1.4-4.2], p = 0.001). Blended capitation practices had a significantly higher percentage of patients who had their waistlines monitored than in fee-for-service practices (19% vs. 5%, AOR = 3.7 [1.8-7.8], p = 0.0006), and who were recommended a smoking cessation drug when compared to community health centres (33% vs. 16%, AOR = 2.4 [1.3-4.6], p = 0.007). Overall, quality of diabetes care was higher in community health centres, while smoking cessation care and weight management was higher in the blended-capitation models. Fee-for-service practices had the greatest gaps in care, most noticeably in diabetes care and weight management. CONCLUSIONS: This study adds to the evidence suggesting that primary care delivery model impacts quality of care. These findings support current Ontario reforms to move away from the traditional fee-for-service practice. TRIAL REGISTRATION: ClinicalTrials.gov: NCT00574808.

Income development of General Practitioners in eight European countries from 1975 to 2005.

BACKGROUND: This study aims to gain insight into the international development of GP incomes over time through a comparative approach. The study is an extension of an earlier work (1975-1990, conducted in five yearly intervals). The research questions to be addressed in this paper are: 1) How can the remuneration system of GPs in a country be characterized? 2) How has the annual GP income developed over time in selected European countries? 3) What are the differences in GP incomes when differences in workload are taken into account? And 4) to what extent do remuneration systems, supply of GPs and gate-keeping contribute to the income position of GPs? METHODS: Data were collected for Belgium, Denmark, Germany, Finland, France, the Netherlands, Sweden and the United Kingdom. Written sources, websites and country experts were consulted. The data for the years 1995 and 2000 were collected in 2004-2005. The data for 2005 were collected in 2006-2007. RESULTS: During the period 1975-1990, the income of GPs, corrected for inflation, declined in all the countries under review. During the period 1995-2005, the situation changed significantly: The income of UK GPs rose to the very top position. Besides this, the gap between the top end (UK) and bottom end (Belgium) widened considerably. Practice costs form about 50% of total revenues, regardless of the absolute level of revenues. Analysis based on income per patient leads to a different ranking of countries compared to the ranking based on annual income. In countries with a relatively large supply of GPs, income per hour is lower. The type of remuneration appeared to have no effect on the financial position of the GPs in the countries in this study. In countries with a gate-keeping system the average GP income was systematically higher compared to countries with a direct-access system. CONCLUSION: There are substantial differences in the income of GPs among the countries included in this study. The discrepancy between countries has increased over time. The income of British GPs showed a marked increase from 2000 to 2005, due to the introduction of a new contract between the NHS and GPs.

Towards incentivising integration: A typology of payments for integrated care.

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.

Trends in Medicaid nursing home reimbursement: 1978-89.

Medicaid nursing home reimbursement is of concern because of implications for nursing home expenditures. This article presents data on State Medicaid nursing home reimbursement methods, ratesetting methods, and average per diem rates, refining earlier data and updating through 1989. A trend in the early 1980s toward adopting prospective systems played out by the end of the decade. There were trends, however, toward casemix methods, which may increase access for high-need patients, and toward cost-center limits on nursing, which may provide incentives to lower quality care. Analysis supports previous findings that prospective systems allow greater control over increases in rates.

Reconciling medical expenditure estimates from the MEPS and the NHA, 1996.

This article compares 1996 estimates of national medical care expenditures from the Medical Expenditure Panel Survey (MEPS) and the National Health Accounts (NHA). The MEPS estimate for total expenditures in 1996 was $548 billion; whereas, the NHA estimate for personal health care (PHC) in 1996 was $912 billion. Much of this apparent difference, however, arises from differences in scope between MEPS and NHA--rather than from differences in estimates for comparably-defined expenditures. We adjusted the NHA for differences in included populations and types of services covered, finding a much smaller difference between MEPS and a comparably-defined NHA.

Assessing the impact of payment method and practice setting on German physicians' practice patterns.

This project determined the impact that a physician's practice setting and reimbursement method has on his or her practice behavior. Multivariate regressions that controlled for physician, patient, and practice characteristics were conducted. The primary data source was a questionnaire that sampled ambulatory physicians practicing in the state of Brandenburg, Germany. This research demonstrated that physicians paid on a fee-for-service basis differ significantly from practitioners paid a salary in captured utilization measures: more patient visits per week, including more follow-up visits; a decreased rate of hospitalization; and an increased likelihood of making house calls. A group practice setting demonstrated little impact when compared with a solo practice.

A typology for provider payment systems in health care.

A typology to classify provider payment systems from an incentive point of view is developed. We analyse the way, how these systems can influence provider behaviour and, a fortiori, contribute to attain the general objectives of health care, i.e. quality of care, efficiency and accessibility. The first dimension of the typology indicates whether there is a link between the provider's income and his activity. In variable systems, the provider has an ability to influence his earnings, contrary to fixed systems. The second dimension indicates whether the provider's payments are related to his actual costs or not. In retrospective systems, the provider's own costs are the basis for reimbursement ex post whereas in prospective systems payments are determined ex ante without any link to the real costs of the individual provider. These different characteristics are likely to influence provider behaviour in different ways. Furthermore the most frequently used criteria to determine the provider's income are discussed: per service, per diem, per case, per patient and per period. Also a distinction is made between incentives at the level of the individual provider (micro-level) and the sponsor (macro-level). Finally, the potential interactions when several payment systems are used simultaneously are discussed. This typology is useful to classify and compare different types of payment systems as prevailing in different countries, and provides a useful framework for future research of health care payment systems.

Survey of the degree to which critical care nurses are performing current procedural terminology-coded services.

PURPOSE: To identify the degree to which current procedural terminology-coded services are provided by critical care nurses. Current procedural terminology codes are used by government and private insurers for reimbursement for office, home, hospital, nursing home and emergency department services. METHOD: Out of 100 randomly selected registered nurses invited to participate in this national survey, 43 completed the survey questionnaire. The majority of respondents were 18 to 40 years old, had a bachelor's degree, had practiced nursing between 5 and 10 years, and were employed as staff or charge nurses in an intensive care or emergency room setting. RESULTS: More than 70% of the group were found to perform 28 codes. The codes performed by the greatest number (42) were blood or blood component transfusion and cardiopulmonary resuscitation. One-way analysis of variance applied to the amount of supervision the nurses received while performing the codes and the educational level of the nurses revealed a significant difference between the groups. Post hoc analysis of all possible group comparisons showed that diploma-prepared nurses reported significantly more supervision than nurses having a bachelor's or master's degree. CONCLUSION: This exploratory study indicates that critical care nurses frequently perform selected codes with little or no supervision by a physician.

General dental practitioners' beliefs on the perceived effects of and their preferences for remuneration mechanisms.

OBJECTIVE: To identify GDPs preferences for differing remuneration mechanisms and their beliefs on the effect of the mechanisms in care provision. DESIGN: Postal questionnaire survey of 300 GDPs holding an NHS contract with a London Health Authority. RESULTS: GDPs perceive that remuneration mechanisms are important in determining the provision of care but not overall disease levels. There were differences in the preferred remuneration mechanisms when working under the NHS compared with the non-NHS sector. When providing care under the NHS, either the current remuneration system or a salaried plus bonus would be the preferred choice, while for non-NHS care a fee-per-item mechanism is preferred. Fee-per-item arrangement was the preferred choice of younger general practitioners compared with older practitioners. Females showed a greater preference for a salaried with bonus arrangement compared with males. CONCLUSIONS: If policy makers are to use remuneration mechanisms to influence the provision of care effectively, the beliefs that care providers hold about various mechanisms are important to understand how they would respond to changes in the system.

Revision of the CPI hospital services component.

Upcoming modifications are designed to capture current service delivery patterns, reimbursement methods, and payment sources for hospital visits, rather than what the hospital charges for individual treatment inputs; the result will be an index that better reflects price changes in the dynamic health care field.

Sorting out the three Rs: RVU, RVS and RBRVS.

This article relates the use of relative value units from its historical function of measuring productivity to how it has influenced the structure of national fee schedules. A comparative perspective is presented of the two fee schedules establishing professional rates of reimbursement from Medicare for radiology (RVS), and for all physicians (RBRVS).

Coding consultations versus referrals.

Providers can expedite reimbursement and avoid nomenclature errors by properly differentiating between consultations and referrals. Since consultations allow higher levels of reimbursement, providers will also avoid possible fraud and abuse charges because of such mislabeling.

The American Dental Trade Association looks at dental reimbursement: responsible consumption of appropriate dental services. Managed Care Task Force of the American Dental Trade Association.

The American Dental Trade Association Managed Care Task Force has provided an extensive study of the effects of reimbursement on the dental profession and the dental trade industry. There is great variety among the needs of patients and in the reimbursement plans available. ADTA is urged to take a leadership position to ensure that programs do not restrict access, value, or quality. The key to this strategy will be communicating a consistent message to dentists, patients, benefit managers, and the research community. The message is: "Responsible consumption of appropriate dental services."

[Description of the severely injured in the DRG system: is treatment of the severely injured still affordable?]. / Abbildung von Schwerverletzten im DRG-System : Wird die Schwerverletztenversorgung doch bezahlbar?

BACKGROUND: Due to the heterogeneity of severely injured patients (multiple trauma) it is difficult to assign them to homogeneic diagnosis-related groups (DRG). In recent years this has led to a systematic underfunding in the German reimbursement system (G-DRG) for cases of multiply injured patients. This project aimed to improve the reimbursement by modifying the case allocation algorithms of multiply injured patients within the G-DRG system. METHODS: A retrospective analysis of standardized G-DRG data according to §21 of the Hospital Reimbursement Act (§ 21 KHEntgG) including case-related cost data from 3,362 critically injured patients from 2007 and 2008 from 10 university hospitals and 7 large municipal hospitals was carried out. For 1,241 cases complementary detailed information was available from the trauma registry of the German Trauma Society to monitor the case allocation of multiply injured patients within the G-DRG system. Analysis of coding and grouping, performance of case allocation and the homogeneity of costs in the G-DRG versions 2008-2012 was carried out. RESULTS: The results showed systematic underfunding of trauma patients in the G-DRG version 2008 but adequate cost covering in the majority of cases with the G-DRG versions 2011 and 2012. Cost coverage was foundfor multiply injured patients from the clinical viewpoint who were identified as multiple trauma by the G-DRG system. Some of the overfunded trauma patients had high intensive care costs. Also there was underfunding for multiple injured patients not identified as such in the G-DRG system. CONCLUSIONS: Specific modifications of the G-DRG allocation structures could increase the appropriateness of reimbursement of multiply injured patients. Data-based analysis is an essential prerequisite for a constructive development of the G-DRG system and a necessary tool for the active participation of medical specialist societies.