Primary care providers' preferences for pay-for-performance programs: a discrete choice experiment study in Shandong China.

BACKGROUND: Pay-for-performance (P4P) schemes are commonly used to incentivize primary healthcare (PHC) providers to improve the quality of care they deliver. However, the effectiveness of P4P schemes can vary depending on their design. In this study, we aimed to investigate the preferences of PHC providers for participating in P4P programs in a city in Shandong province, China. METHOD: We conducted a discrete choice experiment (DCE) with 882 PHC providers, using six attributes: type of incentive, whom to incentivize, frequency of incentive, size of incentive, the domain of performance measurement, and release of performance results. Mixed logit models and latent class models were used for the statistical analyses. RESULTS: Our results showed that PHC providers had a strong negative preference for fines compared to bonuses (- 1.91; 95%CI - 2.13 to - 1.69) and for annual incentive payments compared to monthly (- 1.37; 95%CI - 1.59 to - 1.14). Providers also showed negative preferences for incentive size of 60% of monthly income, group incentives, and non-release of performance results. On the other hand, an incentive size of 20% of monthly income and including quality of care in performance measures were preferred. We identified four distinct classes of providers with different preferences for P4P schemes. Class 2 and Class 3 valued most of the attributes differently, while Class 1 and Class 4 had a relatively small influence from most attributes. CONCLUSION: P4P schemes that offer bonuses rather than fines, monthly rather than annual payments, incentive size of 20% of monthly income, paid to individuals, including quality of care in performance measures, and release of performance results are likely to be more effective in improving PHC performance. Our findings also highlight the importance of considering preference heterogeneity when designing P4P schemes.

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.

The evidence gap on gendered impacts of performance-based financing among family physicians for chronic disease care: a systematic review reanalysis in contexts of single-payer universal coverage.

BACKGROUND: Although pay-for-performance (P4P) among primary care physicians for enhanced chronic disease management is increasingly common, the evidence base is fragmented in terms of socially equitable impacts in achieving the quadruple aim for healthcare improvement: better population health, reduced healthcare costs, and enhanced patient and provider experiences. This study aimed to assess the literature from a systematic review on how P4P for diabetes services impacts on gender equity in patient outcomes and the physician workforce. METHODS: A gender-based analysis was performed of studies retrieved through a systematic search of 10 abstract and citation databases plus grey literature sources for P4P impact assessments in multiple languages over the period January 2000 to April 2018, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The study was restricted to single-payer national health systems to minimize the risk of physicians sorting out of health organizations with a strong performance pay component. Two reviewers scored and synthesized the integration of sex and gender in assessing patient- and provider-oriented outcomes as well as the quality of the evidence. FINDINGS: Of the 2218 identified records, 39 studies covering eight P4P interventions in seven countries were included for analysis. Most (79%) of the studies reported having considered sex/gender in the design, but only 28% presented sex-disaggregated patient data in the results of the P4P assessment models, and none (0%) assessed the interaction of patients' sex with the policy intervention. Few (15%) of the studies controlled for the provider's sex, and none (0%) discussed impacts of P4P on the work life of providers from a gender perspective (e.g., pay equity). CONCLUSIONS: There is a dearth of evidence on gender-based outcomes of publicly funded incentivizing physician payment schemes for chronic disease care. As the popularity of P4P to achieve health system goals continues to grow, so does the risk of unintended consequences. There is a critical need for research integrating gender concerns to help inform performance-based health workforce financing policy options in the era of the Sustainable Development Goals.

How should community health workers in fragile contexts be supported: qualitative evidence from Sierra Leone, Liberia and Democratic Republic of Congo.

BACKGROUND: Community health workers (CHWs) are critical players in fragile settings, where staff shortages are particularly acute, health indicators are poor and progress towards Universal Health Coverage is slow. Like other health workers, CHWs need support to contribute effectively to health programmes and promote health equity. Yet the evidence base of what kind of support works best is weak. We present evidence from three fragile settings-Sierra Leone, Liberia and Democratic Republic of Congo on managing CHWs, and synthesise recommendations for best approaches to support this critical cadre. METHODS: We used a qualitative study design to explore how CHWs are managed, the challenges they face and potential solutions. We conducted interviews with decision makers and managers (n = 37), life history interviews with CHWs (n = 15) and reviewed policy documents. RESULTS: Fragility disrupts education of community members so that they may not have the literacy levels required for the CHW role. This has implications for the selection, role, training and performance of CHWs. Policy preferences about selection need discussion at the community level, so that they reflect community realities. CHWs' scope of work is varied and may change over time, requiring ongoing training. The modular, local and mix of practical and classroom training approach worked well, helping to address gender and literacy challenges and developing a supportive cohort of CHWs. A package of supervision, community support, regular provision of supplies, performance rewards and regular remuneration is vital to retention and performance of CHWs. But there are challenges with supervision, scarcity of supplies, inadequate community recognition and unfulfilled promises about allowances. Clear communication about incentives with facility staff and communities is required as is their timely delivery. CONCLUSIONS: This is the first study that has explored the management of CHWs in fragile settings. CHWs' interface role between communities and health systems is critical because of their embedded positionality and the trusting relationships they (often) have. Their challenges are aligned to those generally faced by CHWs but chronic fragility exacerbates them and requires innovative problem solving to ensure that countries and communities are not left behind in reforming the way that CHWs are supported.

Performance Metrics in Hand Surgery: Turning a Blind Eye Will Cost You.

The Medicare Access and Children's Health Insurance Program Reauthorization Act established the Quality Payment Program (QPP), which mandates that physicians who meet the threshold in volume of Medicare patients for whom they care participate in this program through either advanced Alternative Payment Models or the Merit-Based Incentive Payment System. Anticipating physicians' concerns regarding the burden of implementing the QPP, feedback from physicians became a critical component of the continued implementation process in 2018. The purpose of this review is to inform hand surgeons regarding the current QPP (early 2019) and for future observation periods.

Gendered effects of pay for performance among family physicians for chronic disease care: an economic evaluation in a context of universal health coverage.

BACKGROUND: Despite increasing popularity among health organizations of pay for performance (P4P) for the provision of comprehensive care for chronic non-communicable diseases, evidence of its effectiveness in improving health system outcomes is weak. An important void in the evidence base is whether there are gendered differences in P4P uptake and in related outcomes amenable to healthcare improvement. This study assesses the gender-specific effects of P4P among family physicians on diabetes healthcare costs in a context of universal health coverage. METHODS: We use population-based linked longitudinal administrative datasets on chronic disease cases, physician billings, hospital discharge abstracts, and physician and resident registries in the province of New Brunswick, Canada. We estimate the effects of introduction of a P4P scheme on excess public healthcare costs among cohorts of adult diabetes patients using propensity score-adjusted difference-in-differences regressions stratified by physician's gender. RESULTS: We observed greater male physician uptake of incentive payments, seemingly exacerbating gender gaps in professional remuneration. Regression results indicated P4P did not lead to improved outcomes in terms of preventing hospitalization costs among patients, only measurable increases in compensation for both the male and female physician workforce. CONCLUSIONS: While P4P was not attributed in this study to reduced hospital burden and enhanced sustainability of healthcare financing, incentive payments were found to be related to earning gaps by physician's gender. Decision-makers should consider that benefits of P4P be monitored not only for patient metrics but also for provider metrics in terms of gender equality especially given feminization of primary care medical workforces.

Physician Payment after the SGR--The New Meritocracy.

With the Merit-Based Incentive Payment System, Medicare shifts from payment based on macroeconomic indicators to relying on physician- or group-level indicators of cost and quality--and could create a large fee differential between high- and low-performing physicians.

Performance-based financing kick-starts motivational "feedback loop": findings from a process evaluation in Mozambique.

BACKGROUND: Performance-based financing (PBF) reforms aim to directly influence health worker behavior through changes to institutional arrangements, accountability structures, and financial incentives based on performance. While there is still some debate about whether PBF influences extrinsic or intrinsic motivators, recent research finds that PBF affects both. Against this backdrop, our study presents findings from a process evaluation of a PBF program in Mozambique, exploring the perceived changes to both internal and external drivers of health worker motivation associated with PBF. METHODS: We used a qualitative research design with in-depth, semi-structured interviews with health workers, which included a rank order exercise and focus group discussions. Interviews were analyzed by two researchers using thematic analysis techniques. Rank order frequency was calculated using weighted average methodology. RESULTS: Health workers reported that PBF, overall, positively influenced their motivation by introducing or reinforcing both internal and external motivational drivers. Internal drivers included enhanced self-efficacy driven by goal orientation, healthy competition among colleagues, and job satisfaction. External drivers included an organized work environment, enhanced access to equipment and supplies, financial incentives, teamwork, and regular consultations with verifiers (a type of supervision). PBF stimulates an interactive relationship between internal and external motivational drivers, creating a feedback loop involving responsibility, achievement, and recognition, which increased perceived motivation. CONCLUSIONS: The PBF program helped workers feel that they had well-defined and achievable goals and that they received recognition from verification teams, management committees, and colleagues due to enhanced accountability and governance. Our paper shows that financial incentives could serve as the "driver" to kick-start the feedback loop, of responsibility, achievement, and recognition, in environments that lack other drivers. Understanding how PBF programs can be designed and refined to reinforce this feedback loop could be a powerful tool to further enhance and track positive motivational changes. For countries thinking about PBF, we recommend that policymakers assess the loop in their contexts, identify drivers, determine whether these drivers are sufficient, and consider PBF if they are not. TRIAL REGISTRATION: We obtained ethical approval for the study protocol, data collection instruments, and informed consent forms from the Ethics Review Committee of the Centers for Disease Control and Prevention (CDC) [IRB 2015-190] and the Ethics Review Committee of the Mozambique Ministry of Health.

What characteristics of provider payment mechanisms influence health care providers' behaviour? A literature review.

BACKGROUND: Provider payment mechanisms (PPMs) create incentives or signals that influence the behaviour of health care providers. Understanding the characteristics of PPMs that influence health care providers' behaviour is essential for aligning PPM reforms for improving access, quality, and efficiency of health care services. We reviewed empirical literature that examined the characteristics of PPMs that influence the behaviour of health care providers. METHODS: We systematically searched for empirical literature in PubMed, Web of Science, and Google Scholar databases and complemented these with physical searching of the references of selected papers for further relevant studies. A total of 16 studies that met our inclusion and exclusion criteria were identified. We analysed data using thematic review. RESULTS: We identified seven major characteristics of PPMs that influence health care providers' behaviour. Of these characteristics, payment rate, the sufficiency of payment rate to cover the cost of services, timeliness of payment, payment schedule, performance requirements, and accountability mechanisms were the most important. CONCLUSIONS: Our review found that health care providers' behaviour is influenced by the characteristics of PPMs. Provider payment mechanism reforms that optimally structure these characteristics can elicit required incentives for access, equity, quality, and efficiency in service delivery among health care providers towards achieving universal health coverage.

Payment system of urban family physician programme in the Islamic Republic of Iran: is it appropriate?

BACKGROUND: The payment system is pivotal in implementing policies in the health sector. Equitable access to healthcare is the main principle of the payment system. AIMS: This study aimed to investigate aspects of the payment system in the urban family physician programme (FPP) in the Islamic Republic of Iran. METHODS: This was a qualitative study. We obtained data from key informants and both formal and grey literature. We used content analysis for data analysis. RESULTS: A range of concepts was explored related to the payment system of the FPP. By merging similar expressions, we categorized the findings into four main themes including: payment method, payment criteria and incentives, payment process and amount of payment. CONCLUSIONS: FPP is required to follow convenient implementation methods. The mechanisms of payment in the health sector are weak and have no transparency. A blurred combination of criteria makes an unclear process for determining the payment mechanisms. It is recommended that the opinions of key stakeholders be taken into consideration prior to developing payment mechanisms and financial incentives.

MACRA and the Changing Medicare Payment Landscape.

BACKGROUND: The Medicare Access and CHIP Reauthorization Act (MACRA) is being implemented in 2017 by the Centers for Medicare and Medicaid Services (CMS) as the Quality Payment Program (QPP) and will have important and far reaching effects on how physicians are reimbursed and on how they practice. The QPP modifies the Medicare physician payment system by eliminating the Sustainable Growth Rate formula and incorporating the existing Physician Quality Reporting System, EHR Incentive Program, and the Value Modifier into a single new Merit-based Incentive Payment System (MIPS). METHODS: The authors reviewed the MACRA legislation as well as the CMS resources on the QPP and other sources to summarize the regulations pertaining to the new program, particularly for the first performance period. RESULTS: CMS has taken great care to create a smooth transition for Medicare physicians. Clinicians can avoid any penalty for performance in 2017 by submitting a minimal amount of quality data, attesting to a single improvement activity, or successfully attaining the base score for the advancing care information portion of MIPS. The reduced reporting period also makes it possible for participants to begin collecting data as late as October 2nd and still achieve the full possible score in the program. CONCLUSIONS: Surgeons should be taking steps now to ensure that they are prepared to succeed in the QPP. The transition period creates a clear pathway for avoiding penalties while providing an opportunity to test one's ability to participate and improve performance.

Future considerations for clinical dermatology in the setting of 21st century American policy reform: The Medicare Access and Children's Health Insurance Program Reauthorization Act and the Merit-based Incentive Payment System.

As the implementation of the Medicare Access and Children's Health Insurance Program Reauthorization Act begins, many dermatologists who provide Medicare Part B services will be subject to the reporting requirements of the Merit-based Incentive Payment System (MIPS). Clinicians subject to MIPS will receive a composite score based on performance across 4 categories: quality, advancing care information, improvement activities, and cost. Depending on their overall MIPS score, clinicians will be eligible for a positive or negative payment adjustment. Quality will replace the Physician Quality Reporting System and clinicians will report on 6 measures from a list of over 250 options. Advancing care information will replace meaningful use and will assess clinicians on activities related to integration of electronic health record technology into their practice. Improvement activities will require clinicians to attest to completion of activities focused on improvements in care coordination, beneficiary engagement, and patient safety. Finally, cost will be determined automatically from Medicare claims data. In this article, we will provide a detailed review of the Medicare Access and Children's Health Insurance Program Reauthorization Act with a focus on MIPS and briefly discuss the potential implications for dermatologists.

Incentives to change: effects of performance-based financing on health workers in Zambia.

BACKGROUND: Performance-based financing (PBF) has been implemented in a number of countries with the aim of transforming health systems and improving maternal and child health. This paper examines the effect of PBF on health workers' job satisfaction, motivation, and attrition in Zambia. It uses a randomized intervention/control design to evaluate before-after changes for three groups: intervention (PBF) group, control 1 (C1; enhanced financing) group, and control 2 (C2; pure control) group. METHODS: Mixed methods are employed. The quantitative portion comprises of a baseline and an endline survey. The survey and sampling scheme were designed to allow for a rigorous impact evaluation of PBF or C1 on several key performance indicators. The qualitative portion seeks to explain the pathways underlying the observed differences through interviews conducted at the beginning and at the three-year mark of the PBF program. RESULTS: Econometric analysis shows that PBF led to increased job satisfaction and decreased attrition on a subset of measures, with little effect on motivation. The C1 group also experienced some positive effects on job satisfaction. The null results of the quantitative assessment of motivation cohere with those of the qualitative assessment, which revealed that workers remain motivated by their dedication to the profession and to provide health care to the community rather than by financial incentives. The qualitative evidence also provides two explanations for higher overall job satisfaction in the C1 than in the PBF group: better working conditions and more effective supervision from the District Medical Office. The PBF group had higher satisfaction with compensation than both control groups because they have higher compensation and financial autonomy, which was intended to be part of the PBF intervention. While PBF could not address all the reasons for attrition, it did lower turnover because those health centers were staffed with qualified personnel and the personnel had role clarity. CONCLUSIONS: In Zambia, the implementation of PBF schemes brought about a significant increase in job satisfaction and a decrease in attrition, but had no significant effect on motivation. Enhanced health financing also increased stated job satisfaction.

A cross-sectional study of the income sources of primary care health workers in the Democratic Republic of Congo.

BACKGROUND: In the Democratic Republic of Congo (DRC), the state system to remunerate health workers is poorly functional, encouraging diversification of income sources and corruption. Given the central role that health workers play in health systems, policy-makers need to ensure health workers are remunerated in a way which best incentivises them to provide effective and good quality services. This study describes the different sources and quantities of income paid to primary care health workers in Equateur, Maniema, Kasai Occidental, Province Orientale and Kasai Oriental provinces. It also explores characteristics associated with the receipt of different sources of income. METHODS: Quantitative data on the income received by health workers were collected through baseline surveys. Descriptive statistics explored the demographic characteristics of health workers surveyed, and types and amounts of incomes received. A series of regression models were estimated to examine the health worker and facility-level determinants of receiving each income source and of levels received. Qualitative data collection was carried out in Kasai Occidental province to explore perceptions of each income source and reasons for receiving each. RESULTS: Nurses made up the majority of workers in primary care. Only 31% received a government salary, while 75% reported compensation from user fees. Almost half of all nurses engaged in supplemental non-clinical activities. Receipt of government payments was associated with income from private practice and non-clinical activities. Male nurses were more likely to receive per diems, performance payments, and higher total remuneration compared to females. Contextual factors such as provincial location, presence of externally financed health programmes and local user fee policy also influenced the extent to which nurses received many income sources. CONCLUSIONS: The receipt of government payments was unreliable and had implications for receipt of other income sources. A mixture of individual, facility and geographical factors were associated with the receipt of various income sources. Greater co-ordination is needed between partners involved in health worker remuneration to design more effective financial incentive packages, reduce the fragmentation of incomes and improve transparency in the payment of workers in the DRC.

Revisiting Incentive-Based Contracts.

Incentive-based pay is rational, intuitive, and popular. Agency theory tells us that a principal seeking to align its incentives with an agent's should be able to simply pay the agent to achieve the principal's desired results. Indeed, this strategy has long been used across diverse industries-from executive compensation to education, professional sports to public service-but with mixed results. Now a new convert to incentive compensation has appeared on the scene: the United States' behemoth health-care industry. In many ways, the incentive mismatch story is the same. Insurance companies and employers are concerned about constraining the cost of care, and patients are concerned about quality of care. Physicians lack an adequate financial incentive to pay attention to either. Health care's recent move away from the traditional fee-for-service compensation model to incentive pay is perhaps unsurprising. But there is a problem: mixed preliminary evidence and potential mal-effects on vulnerable third-party patients. This Article employs a new lens-the legal and behavioral literature on optimal contract specificity-to suggest why incentive pay is problematic and why the health-care experience will be no different than other industries. The use of incentive pay is a change in contractdrafting strategy, a decision to write a more detailed, control-based contract rather than one that relies on discretion. The contracts literature suggests that this strategy will only work well where simple compliance is the goal rather than creativity or innovation. The health industry will not succeed in implementing incentive pay better than other industries have. What it needs is to recognize the limits of incentive pay and implement it sparingly. The new Trump Administration may be particularly primed to heed this call.

MACRA: A New Age for Physician Payments.

The Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 introduced a new system of physician payments in the United States. This legislation and the complex rules written to enact the law intend to force a shift away from volume-based payments and into so called value-based payments. Physicians and other clinicians will be graded via quality and cost metrics and payments will be adjusted based on performance. Robust use of certified electronic health records is required under MACRA. Physicians will follow one of two payment reform tracks known as the Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Model (APM) pathways. Although there are rheumatology and other specialty specific quality measures in the MIPS program, there are no rheumatology specific APMs to date. A thorough understating of MACRA is required for medical practices to survive the new era of payment reform.

Paying for population health: Quality measures are growing as part of execs' pay incentives.

Health system and hospital executive pay is still primarily linked to hitting financial targets, but a growing minority of providers ties CEO paychecks to population health improvement.

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.