RESUMO
The UK Quality and Outcomes Framework rewards general practices for achieving quality indicators for chronic disease management. Some indicators are multi-rewarded. For example, there are indicators for controlling blood pressure for patients with diabetes and for patients with chronic heart disease. Thus if a patient has diabetes and heart disease the practice is rewarded twice for controlling her blood pressure. Other indicators are singly rewarded: the incentivised activity is only for patients with single specific condition. We compare general practice performance on single and multi-reward indicators. We use a 2005/6-2012/13 panel of over 800 Scottish general practices, control for practice characteristics, practice fixed effects, indicator characteristics (whether the indicator was for measurement, treatment, or intermediate outcome, maximum payment, upper thresholds), condition, and year and cluster on indicators. We find that the proportion of patients with a given condition for whom a quality indicator was achieved was higher, and the proportion who were exception reported was lower, for multi-reward indicators than for single reward indicators. We also exploit the replacement of multi-reward smoking indicators by single reward indicators in 2006/7. Compared to indicators which were always single or always multi-reward, the proportion of the relevant patients for whom the smoking indicators were achieved fell when the smoking indicators were no longer multi-reward. Fine details of pay for performance schemes matter: they affect physician behaviour and patient outcomes.
Assuntos
Clínicos Gerais/economia , Clínicos Gerais/psicologia , Reembolso de Incentivo , Medicina Estatal/economia , Contratos , Humanos , Qualidade da Assistência à Saúde , Reino UnidoRESUMO
INTRODUCTION: Integrated care systems as well as accountable care organisations (ACOs) in the US and similar concepts in other countries are advocated as an effective method of improving the performance of healthcare systems. These systems outline a payment and care delivery model that intends to tie provider reimbursements to predefined quality metrics. By this the total costs of care shall be reduced. When designing healthcare options contractors are faced with a variety of financial options. The costs of market utilisation are highly relevant for the conception of healthcare contracts; furthermore contract-specific investments are an obstacle to the efficient operation of ACOs. METHODS: A comprehensive literature review on methods of designing contracts in Integrated Care was conducted. This article is the second in a row of three that are all published in this issue and contribute to a specific issue in designing healthcare contracts. The first dealt with the organisation of contracts and information asymmetries, while part 3 concludes with the question of risk management and evaluation. The specific research question of this second article focusses on the financial options and reimbursement schemes that are available to define healthcare contracts. RESULTS: A healthcare contract is a relational contract, which determines the level of reimbursement, the scope of services and the quality between service providers and payers, taking account of the risks relating to population and performance. A relational contract is an agreement based upon assumption of a longer timeframe. A major obstacle to the practical implementation of healthcare contracts is the prognosis of the inflows and outflows due to the actuarial risks of the insured population. Financing conditions and reimbursement arrangements that are based on a prospectively determined fixed price, have a significant drawback: it is very difficult to take the differences in health status and the utilisation of distinct insured clientele (panel) into account. DISCUSSION AND CONCLUSION: The first two articles of this series on contract design have shown that complete contracts in healthcare are unrealistic. Healthcare reimbursement contracts are incomplete contracts with a high degree of uncertainty. In incomplete contracts specific contractual regulations are not made for any eventuality. For this reason it is important that the parties agree on the prevention of endogenous risks (asymmetric information after the conclusion of the contract) and on the procedure in the case of unforeseen circumstances (the risks of random, parameter risk and change risks to the healthcare program).