Is pay for performance promoting inverse inequality in Irish general practice?

BACKGROUND: In 2020, the Chronic Disease Management (CDM) programme was introduced in Ireland. This programme resources GPs to review public (GMS) patients, diagnosed with eight named chronic diseases, twice yearly according to a structured protocol. This pay for performance initiative has been widely adopted by GPs. However, it is hypothesised that private patients (PPs) receive a poorer standard of care, as they may be reluctant to attend due to the cost involved. AIM: To assess whether the management of eight chronic diseases named in the CDM programme is to the same standard among both PPs and GMS patients. METHOD: A retrospective audit of GP practices in the Midwest of Ireland. Data relating to 25 GMS patients and 25 PPs, matched by age, gender, and clinical condition, is collected from each practice. Patients have at least 1 of the eight named chronic diseases. Parameters include vaccination status (influenza, pneumococcal, COVID); body mass index; blood pressure; smoking status; renal function; HbA1c; lipid profile; brain natriuretic peptide (BNP) in patients with heart failure; and lung function tests in patients with COPD or asthma. COVID vaccination status acts as a control because it is freely available for both PPs and GMS patients. RESULTS: Preliminary results from 2 GP practices show large consistent disparities in management between PPs and GMS patients in most parameters. CONCLUSION: Limiting Pay for Performance to the care of GMS patients only, based on age or income, promotes inverse inequality. We argue that CDM care should be offered to all patients.

Can financial incentives improve access to care? Evidence from a French experiment on specialist physicians.

In France, addressing balance billing is essential for equitable healthcare access and reducing physician income disparities. The National Health Insurance (NHI) introduced financial incentive programs, namely the "Contract for Access to Care" (CAS) in 2014 and the "Option for Controlled Pricing" (OPTAM) in 2017, to encourage physicians to reduce extra fees and adhere to regulated prices. This study analyzed the impact of these programs on self-employed physicians using a comprehensive administrative dataset covering specialist physicians from 2005 to 2017. The dataset comprised 9891 surgical specialists (30,972 observations) and 6926 medical specialists (21,650 observations) between 2005 and 2017. Applying a difference-in-differences design with a two-way fixed effect model and matching through the "Coarsened Exact Matching" method, the study examined CAS and/or OPTAM membership effects on physicians' activity and fees. The results indicate that both the CAS and OPTAM successfully enhance access to care. Physicians treat more patients, particularly those with lower incomes who might have previously avoided care because of the extra fees. However, an increased patient load translates to a higher workload for physicians. Despite a fee increase, it was observed to be smaller than the surge in activity. Furthermore, if all physicians are appropriately rewarded for their efforts, this improvement in access comes at a cost to NHI. This study's findings provide crucial insights into the nuanced effects of these financial incentive programs on physicians' behavior, highlighting the tradeoff between improved access and increased NHI costs. Ultimately, these findings underscore the complexity of balancing financial incentives, physician workload, and healthcare accessibility in pursuit of a more equitable healthcare system.

Assessing the uptake of incentivised physical health checks for people with serious mental illness: a cohort study in primary care.

BACKGROUND: People with serious mental illness are more likely to experience physical illnesses. The onset of many of these illnesses can be prevented if detected early. Physical health screening for people with serious mental illness is incentivised in primary care in England through the Quality and Outcomes Framework (QOF). GPs are paid to conduct annual physical health checks on patients with serious mental illness, including checks of body mass index (BMI), cholesterol, and alcohol consumption. AIM: To assess the impact of removing and reintroducing QOF financial incentives on uptake of three physical health checks (BMI, cholesterol, and alcohol consumption) for patients with serious mental illness. DESIGN AND SETTING: Cohort study using UK primary care data from the Clinical Practice Research Datalink between April 2011 and March 2020. METHOD: A difference-in-difference analysis was employed to compare differences in the uptake of physical health checks before and after the intervention, accounting for relevant observed and unobserved confounders. RESULTS: An immediate change was found in uptake after physical health checks were removed from, and after they were added back to, the QOF list. For BMI, cholesterol, and alcohol checks, the overall impact of removal was a reduction in uptake of 14.3, 6.8, and 11.9 percentage points, respectively. The reintroduction of BMI screening in the QOF increased the uptake by 10.2 percentage points. CONCLUSION: This analysis supports the hypothesis that QOF incentives lead to better uptake of physical health checks.

Are Quality Scores in the Centers for Medicaid and Medicare Services Merit-based Incentive Payment System Associated With Outcomes After Outpatient Orthopaedic Surgery?

BACKGROUND: The Medicare Merit-based Incentive Payment System (MIPS) ties reimbursement incentives to clinician performance to improve healthcare quality. It is unclear whether the MIPS quality score can accurately distinguish between high-performing and low-performing clinicians. QUESTIONS/PURPOSES: (1) What were the rates of unplanned hospital visits (emergency department visits, observation stays, or unplanned admissions) within 7, 30, and 90 days of outpatient orthopaedic surgery among Medicare beneficiaries? (2) Was there any association of MIPS quality scores with the risk of an unplanned hospital visit (emergency department visits, observation stays, or unplanned admissions)? METHODS: Between January 2018 and December 2019, a total of 605,946 outpatient orthopaedic surgeries were performed in New York State according to the New York Statewide Planning and Research Cooperative System database. Of those, 56,772 patients were identified as Medicare beneficiaries and were therefore potentially eligible. A further 34% (19,037) were excluded because of missing surgeon identifier, age younger than 65 years, residency outside New York State, emergency department visit on the same day as outpatient surgery, observation stay on the same claim as outpatient surgery, and concomitant high-risk or eye procedures, leaving 37,735 patients for analysis. The database does not include a list of all state residents and thus does not allow for censoring of patients who move out of state. We chose this dataset because it includes nearly all hospitals and ambulatory surgery centers in a large geographic area (New York State) and hence is not limited by sampling bias. We included 37,735 outpatient orthopaedic surgical encounters among Medicare beneficiaries in New York State from 2018 to 2019. For the 37,735 outpatient orthopaedic surgical procedures included in our study, the mean ± standard deviation age of patients was 73 ± 7 years, 84% (31,550) were White, and 59% (22,071) were women. Our key independent variable was the MIPS quality score percentile (0 to 19th, 20th to 39th, 40th to 59th, or 60th to 100th) for orthopaedic surgeons. Clinicians in the MIPS program may receive a bonus or penalty based on the overall MIPS score, which ranges from 0 to 100 and is a weighted score based on four subscores: quality, promoting interoperability, improvement activities, and cost. The MIPS quality score, which attempts to reward clinicians providing superior quality of care, accounted for 50% and 45% of the overall MIPS score in 2018 and 2019, respectively. Our main outcome measures were 7-day, 30-day, and 90-day unplanned hospital visits after outpatient orthopaedic surgery. To determine the association between MIPS quality scores and unplanned hospital visits, we estimated multivariable hierarchical logistic regression models controlling for MIPS quality scores; patient-level (age, race and ethnicity, gender, and comorbidities), facility-level (such as bed size and teaching status), surgery and surgeon-level (such as surgical procedure and surgeon volume) covariates; and facility-level random effects. We then used these models to estimate the adjusted rates of unplanned hospital visits across MIPS quality score percentiles after adjusting for covariates in the multivariable models. RESULTS: In total, 2% (606 of 37,735), 2% (783 of 37,735), and 3% (1013 of 37,735) of encounters had an unplanned hospital visit within 7, 30, or 90 days of outpatient orthopaedic surgery, respectively. Most hospital visits within 7 days (95% [576 of 606]), 30 days (94% [733 of 783]), or 90 days (91% [924 of 1013]) were because of emergency department visits. We found very small differences in unplanned hospital visits by MIPS quality scores, with the 20th to 39th percentile of MIPS quality scores having 0.71% points (95% CI -1.19% to -0.22%; p = 0.004), 0.68% points (95% CI -1.26% to -0.11%; p = 0.02), and 0.75% points (95% CI -1.42% to -0.08%; p = 0.03) lower than the 0 to 19th percentile at 7, 30, and 90 days, respectively. There was no difference in adjusted rates of unplanned hospital visits between patients undergoing surgery with a surgeon in the 0 to 19th, 40th to 59th, or 60th to 100th percentiles at 7, 30, or 90 days. CONCLUSION: We found that the rates of unplanned hospital visits after outpatient orthopaedic surgery among Medicare beneficiaries were low and primarily driven by emergency department visits. We additionally found only a small association between MIPS quality scores for individual physicians and the risk of an unplanned hospital visit after outpatient orthopaedic surgery. These findings suggest that policies aimed at reducing postoperative emergency department visits may be the best target to reduce overall postoperative unplanned hospital visits and that the MIPS program should be eliminated or modified to more strongly link reimbursement to risk-adjusted patient outcomes, thereby better aligning incentives among patients, surgeons, and the Centers for Medicare ad Medicaid Services. Future work could seek to evaluate the association between MIPS scores and other surgical outcomes and evaluate whether annual changes in MIPS score weighting are independently associated with clinician performance in the MIPS and regarding clinical outcomes. LEVEL OF EVIDENCE: Level III, therapeutic study.

[Pay for performance in public directly managed healthcare centers. Part 2: The Spanish National Health System. SESPAS Report 2024]. / Evaluación del rendimiento y compensación en centros sanitarios de gestión directa. Parte 2: el Sistema Nacional de Salud. Informe SESPAS 2024.

In Spain, the compensation model for statutory health personnel is complex, heterogeneous, and more oriented to rewarding complementary functions and activities, than to paying for the actual performance in the position of employee. The various attempts to incorporate incentives have been distorted by a civil service egalitarianist culture, and weak systemic governance. External attractors (private practice, etc.) for healthcare professionals are becoming more important and neutralize many intramural incentives. There are few prospects of relevant or general changes, since the main actors involved are reforms-averse; but some environmental factors can lead to incremental improvements in employment contracts, in the information available to improve benchmarking, and in the creation of islands of good clinical governance and management. The economic scenario, increasingly concerned about inflationary trends and sustainability risks, may have a revitalizing effect of some governance and management reforms.

Use of statewide financial incentives to improve documentation of hernia and mesh characteristics in ventral hernia repair.

BACKGROUND: Documentation of intraoperative details is critical for understanding and advancing hernia care, but is inconsistent in practice. Therefore, to improve data capture on a statewide level, we implemented a financial incentive targeting documentation of hernia defect size and mesh use. METHODS: The Abdominal Hernia Care Pathway (AHCP), a voluntary pay for performance (P4P) initiative, was introduced in 2021 within the statewide Michigan Surgical Quality Collaborative (MSQC). This consisted of an organizational-level financial incentive for achieving 80% performance on eight specific process measures for ventral hernia surgery, including complete documentation of hernia defect size and location, as well as mesh characteristics and fixation technique. Comparisons were made between AHCP and non-AHCP sites in 2021. RESULTS: Of 69 eligible sites, 47 participated in the AHCP in 2021. There were N = 5362 operations (4169 at AHCP sites; 1193 at non-AHCP sites). At AHCP sites, 69.8% of operations had complete hernia documentation, compared to 50.5% at non-AHCP sites (p < 0.0001). At AHCP sites, 91.4% of operations had complete mesh documentation, compared to 86.5% at non-AHCP sites (p < 0.0001). The site-level hernia documentation goal of 80% was reached by 14 of 47 sites (range 14-100%). The mesh documentation goal was reached by 41 of 47 sites (range 4-100%). CONCLUSIONS: Addition of an organizational-level financial incentive produced marked gains in documentation of intra-operative details across a statewide surgical collaborative. The relatively large effect size-19.3% for hernia-is remarkable among P4P initiatives. This result may have been facilitated by surgeons' direct role in documenting hernia size and mesh use. These improvements in data capture will foster understanding of current hernia practices on a large scale and may serve as a model for improvement in collaboratives nationally.

Burden of Social and Behavioral Determinants of Health on Infectious Complications in Emergency General Surgery.

Background: Infectious complications lead to worse post-operative outcomes and are used to compare hospital performance in pay-for-performance programs. However, the impact of social and behavioral determinants of health on infectious complication rates after emergency general surgery (EGS) remains unclear. Patients and Methods: All patients undergoing EGS in the 2019 Nationwide Readmissions Database were included. The primary outcome of the study was the rate of infectious complications within 30 days, defined as a composite outcome including all infectious complications occurring during the index hospitalization or 30-day re-admission. Secondary outcomes included specific infectious complication rates. Multivariable regression analyses were used to study the impact of patient characteristics, social determinants of health (insurance status, median household income in the patient's residential zip code), and behavioral determinants of health (substance use disorders, neuropsychiatric comorbidities) on post-operative infection rates. Results: Of 367,917 patients included in this study, 20.53% had infectious complications. Medicare (adjusted odds ratio [aOR], 1.3; 95% confidence interval [CI], 1.26-1.34; p < 0.001), Medicaid (aOR, 1.24; 95% CI,1.19-1.29; p < 0.001), lowest zip code income quartile (aOR, 1.17; 95% CI, 1.13-1.22; p < 0.001), opioid use disorder (aOR,1.18; 95% CI,1.10-1.29; p < 0.001), and neurodevelopmental disorders (aOR, 2.16; 95% CI, 1.90-2.45; p < 0.001) were identified as independent predictors of 30-day infectious complications. A similar association between determinants of health and infectious complications was also seen for pneumonia, urinary tract infection (UTI), methicillin-resistant Staphylococcus aureus (MRSA) sepsis, and catheter-association urinary tract infection (CAUTI). Conclusions: Social and behavioral determinants of health are associated with a higher risk of developing post-operative infectious complications in EGS. Accounting for these factors in pay-for-performance programs and public reporting could promote fairer comparisons of hospital performance.

Spillover effects of financial incentives for providers onto non-targeted patients: daycase surgery in English hospitals.

BACKGROUND: Incentives for healthcare providers may also affect non-targeted patients. These spillover effects have important implications for the full impact and evaluation of incentive schemes. However, there are few studies on the extent of such spillovers in health care. We investigated whether incentives to perform surgical procedures as daycases affected whether other elective procedures in the same specialties were also treated as daycases. DATA: 8,505,754 patients treated for 92 non-targeted procedures in 127 hospital trusts in England between April and March 2016. METHODS: Interrupted time series analysis of the probability of being treated as a daycase for non-targeted patients treated in six specialties where targeted patients were also treated and three specialties where they were not. RESULTS: The daycase rate initially increased (1.04 percentage points, SE: 0.30) for patients undergoing a non-targeted procedure in incentivised specialties but then reduced over time. Conversely, the daycase rate gradually decreased over time for patients treated in a non-incentivised specialty. DISCUSSION: Spillovers from financial incentives have variable effects over different activities and over time. Policymakers and researchers should consider the possibility of spillovers in the design and evaluation of incentive schemes.

Effects of individual and neighborhood social risks on diabetes pay-for-performance program under a single-payer health system.

BACKGROUND: Enrollment in and adherence to a diabetes pay-for-performance (P4P) program can lead to desirable processes and outcomes of diabetes care. However, knowledge is limited on the potential exclusion of patients with individual or neighborhood social risks or interruption of services in the disease-specific P4P program without mandatory participation under a single-payer health system. OBJECTIVE: To investigate the impact of individual and neighborhood social risks on exclusion from and adherence to the diabetes P4P program of patients with type 2 diabetes (T2D) in Taiwan. METHODS: This study used data from Taiwan's 2009-2017 population-based National Health Insurance Research Database, 2010 Population and Housing Census, and 2010 Income Tax Statistics. A retrospective cohort study was conducted, and study populations were identified from 2012 to 2014. The first cohort comprised 183,806 patients with newly diagnosed T2D, who had undergone follow up for 1 year; the second cohort consisted of 78,602 P4P patients who had undergone follow up for 2 years after P4P enrollment. Binary logistic regression models were used to examine the associations of social risks with exclusion from and adherence to the diabetes P4P program. RESULTS: T2D patients with higher individual social risks were more likely to be excluded from the P4P program, but those with higher neighborhood-level social risks were slightly less likely to be excluded. T2D patients with the higher individual- or neighborhood-level social risks showed less likelihood of adhering to the program, and the person-level coefficient was stronger in magnitude than the neighborhood-level one. CONCLUSIONS: Our results indicate the importance of individual social risk adjustment and special financial incentives in disease-specific P4P programs. Strategies for improving program adherence should consider individual and neighborhood social risks.

Exploring HPV vaccination policy and payer strategies for opportunities to improve uptake in safety-net settings.

Introduction: We explored priorities and perspectives on health policy and payer strategies for improving HPV vaccination rates in safety-net settings in the United States. Methods: We conducted qualitative interviews with policy and payer representatives in the greater Los Angeles region and state of New Jersey between December 2020 and January 2022. Practice Change Model domains guided data collection, thematic analysis, and interpretation. Results: Five themes emerged from interviews with 11 policy and 8 payer participants, including: (1) payer representatives not prioritizing HPV vaccination specifically in incentive-driven clinic metrics; (2) policy representatives noting region-specific HPV vaccine policy options; (3) inconsistent motivation across policy/payer groups to improve HPV vaccination; (4) targeting of HPV vaccination in quality improvement initiatives suggested across policy/payer groups; and (5) COVID-19 pandemic viewed as both barrier and opportunity for HPV vaccination improvement across policy/payer groups. Discussion: Our findings indicate opportunities for incorporating policy and payer perspectives into HPV vaccine improvement processes. We identified a need to translate effective policy and payer strategies, such as pay-for-performance programs, to improve HPV vaccination within safety-net settings. COVID-19 vaccination strategies and community efforts create potential policy windows for expanding HPV vaccine awareness and access.

Scaling up quality in an anesthesia practice.

The resources necessary to improve anesthesia quality and meet reimbursement and regulatory thresholds are scarce, particularly for smaller practices. We examined how small practice integration into a firm with greater resources can facilitate improvements. A mixed-methods analysis was conducted using the data from the US Anesthesia Partners data warehouse, Merit-based Incentive Payment System (MIPS), commercial insurers' surgery length of stay (LOS) databases, anesthesia-specific patient satisfaction surveys, and interviews with practice leadership before and after integration. All integrated practices improved their quality improvement infrastructure and achieved higher MIPS scores, with increased clinician and leadership satisfaction. Patient satisfaction exceeded national benchmarks in all groups, based on 398 392 returned surveys in 2021. Hospital LOS for common operations was shorter, based on a statewide database. This case study demonstrates that partnership with an organization with greater resources can advance anesthesia quality.

Plastic Surgeons and Equity: Are Merit-Based Incentive Payment System Scores Impacted by Minority Patient Caseload?

BACKGROUND: The Centers for Medicare and Medicaid Services introduced the Merit-based Incentive Payment System (MIPS) in 2017 to extend value-based payment to outpatient physicians. The authors hypothesized that the MIPS scores for plastic surgeons are impacted by the existing measures of patient disadvantage, minority patient caseload, and dual eligibility. METHODS: The authors conducted a retrospective cohort study of plastic surgeons participating in Medicare and MIPS using the Physician Compare national downloadable file and MIPS scores. Minority patient caseload was defined as nonwhite patient caseload. The authors evaluated the characteristics of participating plastic surgeons, their patient caseloads, and their scores. RESULTS: Of 4539 plastic surgeons participating in Medicare, 1257 participated in MIPS in the first year of scoring. The average patient caseload is 85% white, with racial/ethnicity data available for 73% of participating surgeons. In multivariable regression, higher minority patient caseload is associated with a lower MIPS score. CONCLUSIONS: As minority patient caseload increases, MIPS scores decrease for otherwise similar caseloads. The Centers for Medicare and Medicaid Services must consider existing and additional measures of patient disadvantage to ensure equitable surgeon scoring.

Oncologist Participation and Performance in the Merit-Based Incentive Payment System.

The merit-based incentive payment system (MIPS) is a value-based payment model created by the Centers for Medicare & Medicaid Services (CMS) to promote high-value care through performance-based adjustments of Medicare reimbursements. In this cross-sectional study, we examined the participation and performance of oncologists in the 2019 MIPS. Oncologist participation was low (86%) compared to all-specialty participation (97%). After adjusting for practice characteristics, higher MIPS scores were observed among oncologists with alternative payment models (APMs) as their filing source (mean score, 91 for APMs vs. 77.6 for individuals; difference, 13.41 [95% CI, 12.21, 14.6]), indicating the importance of greater organizational resources for participants. Lower scores were associated with greater patient complexity (mean score, 83.4 for highest quintile vs. 84.9 for lowest quintile, difference, -1.43 [95% CI, -2.48, -0.37]), suggesting the need for better risk-adjustment by CMS. Our findings may guide future efforts to improve oncologist engagement in MIPS.

Engaging health plans to prioritize HPV vaccination and initiate at age 9.

Health plans can influence pediatric and primary care providers and patients to understand HPV vaccination coverage and increase HPV vaccination uptake. By initiating vaccination at age nine, health plans can lay the groundwork for on-time HPV cancer prevention by age 13. In 2022, the American Cancer Society engaged 28 health plans in a 12-month HPV vaccination learning collaborative in which plans set their own quality improvement targets, implemented multi-pronged interventions, and joined quarterly best-practice sharing calls. Twenty-five of the 28 plans reported including a focus on ages 9 to 10. Preliminary pre-intervention data illustrate that vaccination rates from participating plans follow national trends and reaffirm existing gaps for HPV vaccination. Health plan interventions to address HPV vaccination are consistent with best practices but could be maximized to target initiation at ages 9-10 by using provider and patient reminders, targeted provider education, and dose-specific provider pay for performance and patient incentive programs. Health plans should explore future capacity to analyze non-HEDIS required data, including HPV initiation and HPV vaccination data for adolescents below age 13.

Association Between Individual Primary Care Physician Merit-based Incentive Payment System Score and Measures of Process and Patient Outcomes.

Importance: The Medicare Merit-based Incentive Payment System (MIPS) influences reimbursement for hundreds of thousands of US physicians, but little is known about whether program performance accurately captures the quality of care they provide. Objective: To examine whether primary care physicians' MIPS scores are associated with performance on process and outcome measures. Design, Setting, and Participants: Cross-sectional study of 80 246 US primary care physicians participating in the MIPS program in 2019. Exposures: MIPS score. Main Outcomes and Measures: The association between physician MIPS scores and performance on 5 unadjusted process measures, 6 adjusted outcome measures, and a composite outcome measure. Results: The study population included 3.4 million patients attributed to 80 246 primary care physicians, including 4773 physicians with low MIPS scores (≤30), 6151 physicians with medium MIPS scores (>30-75), and 69 322 physicians with high MIPS scores (>75). Compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly worse mean performance on 3 of 5 process measures: diabetic eye examinations (56.1% vs 63.2%; difference, -7.1 percentage points [95% CI, -8.0 to -6.2]; P < .001), diabetic HbA1c screening (84.6% vs 89.4%; difference, -4.8 percentage points [95% CI, -5.4 to -4.2]; P < .001), and mammography screening (58.2% vs 70.4%; difference, -12.2 percentage points [95% CI, -13.1 to -11.4]; P < .001) but significantly better mean performance on rates of influenza vaccination (78.0% vs 76.8%; difference, 1.2 percentage points [95% CI, 0.0 to 2.5]; P = .045] and tobacco screening (95.0% vs 94.1%; difference, 0.9 percentage points [95% CI, 0.3 to 1.5]; P = .001). MIPS scores were inconsistently associated with risk-adjusted patient outcomes: compared with physicians with high MIPS scores, physicians with low MIPS scores had significantly better mean performance on 1 outcome (307.6 vs 316.4 emergency department visits per 1000 patients; difference, -8.9 [95% CI, -13.7 to -4.1]; P < .001), worse performance on 1 outcome (255.4 vs 225.2 all-cause hospitalizations per 1000 patients; difference, 30.2 [95% CI, 24.8 to 35.7]; P < .001), and did not have significantly different performance on 4 ambulatory care-sensitive admission outcomes. Nineteen percent of physicians with low MIPS scores had composite outcomes performance in the top quintile, while 21% of physicians with high MIPS scores had outcomes in the bottom quintile. Physicians with low MIPS scores but superior outcomes cared for more medically complex and socially vulnerable patients, compared with physicians with low MIPS scores and poor outcomes. Conclusions and Relevance: Among US primary care physicians in 2019, MIPS scores were inconsistently associated with performance on process and outcome measures. These findings suggest that the MIPS program may be ineffective at measuring and incentivizing quality improvement among US physicians.

Prices of new medicines: International analysis and policy options.

Equitable and sustainable access to medicines is a global challenge, including for high-income countries. Over the last two decades, launch prices of new medicines have considerably increased, making some medicines unaffordable for many countries. This article is based on a presentation held by the author at the IQWiG Autumn Symposium in November 2021. The medicine price situation in European countries and beyond is presented informed by international evidence. Medicine prices vary across countries, and for some therapeutic groups (e.g., cancer drugs) medicines are largely unaffordable and/or unsustainable for most countries. Selected policy options to improve affordability, which are commonly applied and considered as potential solutions, are discussed. The article stresses the importance of price regulation, and of transparency of prices and further components across the pharmaceutical value chain. Many governments opted for concluding managed-entry agreements (e.g., pay-for-performance) with confidential discounts to make new medicines with high price tags affordable and/or to manage uncertainty about their performance. However, this policy is linked to limitations, particularly due to its secrecy of discounts. Patent expiry of biological medicines can contribute to affordable access; however, it is important to strategically exploit the biosimilar potential by implementing a mix of appropriate policies to foster competition and enhance the uptake of biosimilar medicines.

The effect of a pay-for-performance program on health-related quality of life for patients with hepatitis in Taiwan.

PURPOSE: Chronic viral hepatitis is a major global public health problem. The guidelines suggest the long-term performance of regular ongoing liver examinations to monitor liver inflammation and screen for hepatocellular carcinoma. However, the effects of regular liver examinations on health-related quality of life (HRQoL) have not been adequately evaluated. Therefore, this study evaluated the effects of regular ongoing examinations on the quality of life of patients with hepatitis. METHODS: A cross-sectional study was conducted from October to December 2016 in four hospitals in northern Taiwan. A hepatitis pay-for-performance (P4P) program was launched in 2010 to ensure that hepatitis patients have regular ongoing liver examinations. The study group consisted of patients who joined and stayed in the program for more than one year. The study assessed HRQoL utilizing the five-level version of the EuroQol-5 Dimension (EQ-5D-5L) and the EuroQoL visual analog scale (EQ-VAS). The responses for the EQ-5D-5L in hepatitis patients were transformed into the EQ-5D index according to the Taiwanese population's value set. Sociodemographic and clinical characteristics were collected by questionnaire, and descriptive statistics were presented. A two-part model and generalized linear model with a Poisson distribution and a log link function, respectively, were used to examine the associations of the EQ-5D index and EQ-VAS score with participation in the hepatitis P4P program. We applied propensity score weighting with inverse probability weighting to control for selection bias. RESULTS: In all, 508 patients (aged 57.6 ± 11.6 years; 60.8% male) were enrolled in this study. The mean (standard deviation, SD) reported EQ-5D index and EQ-VAS scores were 0.93 (0.12) and 75.1 (13.8), and the median (interquartile range, IQR) values were 1 (0.108) and 80 (15), respectively. The study group had a moderately significantly higher EQ-VAS score (mean ratio = 1.029, P < 0.001). However, the differences in the EQ-5D index scores between the study and control groups were not significant. CONCLUSION: Patients with hepatitis partially benefited from receiving hepatitis P4P in Taiwan, which featured regular ongoing liver examinations, in that their EQ-VAS scores were enhanced but not their EQ-5D index scores.

Building a Business Case for Hiring Wound, Ostomy, and Continence Nurses.

OBJECTIVE: To describe how one organization built a business case for a wound, ostomy, and continence (WOC) nurse team expansion. SETTING: The organization is part of a multihospital system; it is an 862-bed, urban, academic medical center with a gastrointestinal surgery program. METHODS: The director of nursing and the WOC nurse staff worked collaboratively to build a staffing proposal. Finding a lack of published staffing guidelines for WOC nurses, researchers assessed workload and volume growth, benchmarked internal and external staffing, and conducted a market comparison. The proposal demonstrated impact on care outcomes related to a reduction in WOC nurses. RESULTS: Based on the case presented, the Off Budget Investment Team committee was satisfied that additional WOC nurse resources would bring both quality and financial value to the organization by reducing hospital-acquired pressure injury (HAPI) incidence and increasing ostomy consults. Approval of additional full-time equivalents was contingent upon a commitment to reduce year-over-year HAPI incidence and to assess the additional costs of treating a HAPI, specific to this organization. CONCLUSIONS: Wound ostomy continence nurses bring value to clinical outcomes that impact patient experience, direct and indirect expenses, rankings, reputation, liability, and pay for performance.