Patient and provider factors associated with enrolment in the pre-end-stage renal disease pay-for-performance programme in Taiwan: a cross-sectional study.

OBJECTIVE: The incidence and prevalence of end-stage renal disease (ESRD) in Taiwan have been ranked the highest worldwide. Therefore, the National Health Insurance Administration has implemented the pre-ESRD pay-for-performance (P4P) programme since November 2006, which had significantly reduced the incidence of dialysis and all-cause mortality. This study aimed to identify the factors associated with the enrolment in the pre-ESRD P4P programme. DESIGN: Cross-sectional study. SETTING: The National Health Insurance research database 2007-2012 in Taiwan. PARTICIPANTS: Patients with prevalent pre-ESRD aged more than 18 years between January 2007 and December 2012 were enrolled. Patient demographics and hospital characteristics between P4P and non-P4P groups were compared. A logistic regression model was used to analyse the factors associated with P4P enrolment, and a generalised estimating equation was used to verify the results. PRIMARY OUTCOME MEASURE: Enrolment in the pre-ESRD P4P programme. RESULTS: In total, 82 991 patients were enrolled in the programme, with a 45.6% participation rate. Patients who were males (adjusted OR (AOR)=0.89, 95% CI=0.86 to 0.91) and employed (AOR=0.95, 95% CI=0.92 to 0.97) had a significantly lower probability to be enrolled in the programme. Older patients (66-75 years old, AOR=1.23, 95% CI=1.14 to 1.33) and those with higher Charlson Comorbidities Index (CCI 5+, AOR=4.01, 95% CI=3.55 to 4.53) tended to be enrolled in the programme, while those in the 76+ years age group were not (AOR=1.03, 95% CI=0.95 to 1.13). Hospitals located in the central (AOR=1.48, 95% CI=1.05 to 2.08) and Kao-Ping regions (AOR=1.62, 95% CI=1.18 to 2.22) also tended to enrol patients in the pre-ESRD P4P programme. Enrolment rates increased over time. CONCLUSION: Pre-ESRD patients of the female gender, greater age and more comorbidities were more likely to be enrolled in the pre-ESRD P4P programme. Healthcare providers and health authorities should focus attention on patients who are male, younger and with less comorbidities to improve the healthcare quality and equality for all pre-ESRD patients.

Moneyball in Medicare.

US policymakers place high priority on tying Medicare payments to the value of care delivered. A critical part of this effort is the Hospital Value-based Purchasing Program (HVBP), which rewards or penalizes hospitals based on their quality and episode-based costs of care and incentivizes integration between hospitals and post-acute care providers. Within HVBP, each patient affects hospital performance on a variety of quality and spending measures, and performance translates directly to changes in program points and ultimately dollars. In short, hospital revenue from a patient consists not only of the DRG payment, but also of that patient's marginal future reimbursement. We estimate the magnitude of the marginal future reimbursement for individual patients across each type of quality and performance measure. We describe how those incentives differ across hospitals, including integrated and safety-net hospitals. We find evidence that hospitals improved their performance over time in the areas where they have the highest marginal incentives to improve care, and that integrated hospitals responded more than non-integrated hospitals.

Impact of financial agreements in European chronic care on health care expenditure growth.

Various types of financial agreements have been implemented in Europe to reduce health care expenditure by stimulating integrated chronic care. This study used difference-in-differences (DID) models to estimate differences in health care expenditure trends before and after the introduction of a financial agreement between 9 intervention countries and 16 control countries. Intervention countries included countries with pay-for-coordination (PFC), pay-for-performance (PFP), and/or all inclusive agreements (bundled and global payment) for integrated chronic care. OECD and WHO data from 1996 to 2013 was used. The results from the main DID models showed that the annual growth of outpatient expenditure was decreased in countries with PFC (by 21.28 US$ per capita) and in countries with all-inclusive agreements (by 216.60 US$ per capita). The growth of hospital and administrative expenditure was decreased in countries with PFP by 64.50 US$ per capita and 5.74 US$ per capita, respectively. When modelling impact as a non-linear function of time during the total 4-year period after implementation, PFP decreased the growth of hospital and administrative expenditure and all-inclusive agreements reduced the growth of outpatient expenditure. Financial agreements are potentially powerful tools to stimulate integrated care and influence health care expenditure growth. A blended payment scheme that combines elements of PFC, PFP, and all-inclusive payments is likely to provide the strongest financial incentives to control health care expenditure growth.

Therapeutic inertia and intensified treatment in diabetes mellitus prescription patterns: A nationwide population-based study in Taiwan.

Objective To measure therapeutic inertia by characterizing prescription patterns using secondary data obtained from the nationwide diabetes mellitus pay-for-performance (DM-P4P) programme in Taiwan. Methods Using reimbursement claims from Taiwan's National Health Insurance Research Database, a nationwide retrospective cohort study was undertaken of patients with diabetes mellitus who participated in the DM-P4P programme from 2006-2008. Glycosylated haemoglobin results were used to evaluate modifications in therapy in response to poor diabetes control. Prescription patterns were used to assign patients to either a therapeutic inertia group or an intensified treatment group. Therapeutic inertia was defined as the failure to act on a known problem. Results The research sample comprised of 168 876 patients with diabetes mellitus who had undergone 899 135 tests. Of these, 37.4% (336 615 visits) of prescriptions were for a combination of two types of drug and 27.7% (248 788 visits) were for a combination of three types of drug. The proportion of patients in the intensified therapy group who were prescribed more than two types of drug was considerably higher than that in the therapeutic inertia group. Conclusion In many cases in the therapeutic inertia group only a single type of hypoglycaemic drug was prescribed or the dosage remained unchanged.

Cumplimiento de indicadores de proceso en personas con diabetes tipo 2 y la vinculación a incentivos en Atención Primaria / Compliance with process indicators in people with type 2 diabetes and linking incentives in Primary Care

OBJETIVO: Los programas de pago por desempeño para mejorar la calidad de la atención sanitaria se están extendiendo de forma progresiva, en particular para en Atención Primaria. Nuestro objetivo fue explorar la relación entre el grado de cumplimiento de los indicadores de proceso (IPr) de la diabetes mellitus tipo 2 (DM2) en Atención Primaria y la vinculación a incentivos económicos. DISEÑO: Estudio descriptivo observacional, descriptivo y transversal. Emplazamiento: Seis centros de salud del Distrito Aljarafe, Sevilla, seleccionados de forma aleatoria y estratificada por tamaño poblacional. PARTICIPANTES: De un total de 3.647 sujetos incluidos en el Proceso Asistencial Integrado de DM2 durante el 2008, se incluyó a 366 pacientes, según cálculo de tamaño muestral, mediante muestreo aleatorio estratificado. Mediciones: IPr: exploración de fondo de ojo y pies, hemoglobina glucosilada (HbA1c), perfil lipídico, microalbuminuria y electrocardiograma. Variables potencialmente confusoras: edad, género, característica de zona de residencia en pacientes y variables de los médicos. RESULTADOS: La edad media fue de 66,36 (desviación estándar -DE- 11,56 años); el 48,9% eran mujeres. Los IPr con mejor cumplimiento fueron la exploración de pies, HbA1c y perfil lipídico (59,6, 44,3 y 44, respectivamente). El 2,7% de los pacientes presentaban cumplimiento simultáneo de los 6 IPr y el 11,74% de los 3 IPr vinculados a incentivos. El cumplimiento de IPr vinculado y no a incentivos mostró asociación significativa (p = 0,001). CONCLUSIONES: El cumplimiento de los IPr para el cribado de complicaciones crónicas de la DM2 es en su mayoría bajo, aunque este fue superior en los indicadores vinculados a incentivos

OBJECTIVE: Pay-for-performance programs to improve the quality of health care are extending gradually, particularly en Primary Health Care. Our aim was to explore the relationship between the degree of compliance with the process indicators (PrI) of type 2 diabetes (T2DM) in Primary Care and linkage to incentives. DESIGN: Cross-sectional, descriptive, observational study. SETTING: Six Primary Health Care centers in Seville Aljarafe District randomly selected and stratified by population size. PARTICIPANTS: From 3.647 adults included in Integrated Healthcare Process of T2DM during 2008, 366 patients were included according sample size calculation by stratified random sampling. Measurements: PrI: eye and feet examination, glycated hemoglobin, lipid profile, microalbuminuria and electrocardiogram. Confounding: Age, gender, characteristics town for patients and professional variables. RESULTS: The mean age was 66.36 years (standard deviation [DE]: 11,56); 48.9% were women. PrI with better compliance were feet examination, glycated hemoglobin and lipid profile (59.6%, 44.3% and 44%, respectively). 2.7% of patients had simultaneous compliance of the six PrI and 11.74% of patients three PrI linkage to incentives. Statistical association was observed in the compliance of the PrI incentives linked or not (P = .001). CONCLUSIONS: The degree of compliance with the PrI for screening chronic complications of T2DM is mostly low but this was higher on indicators linked to incentives

Exploring payment schemes used to promote integrated chronic care in Europe.

The rising burden of chronic conditions has led several European countries to reform healthcare payment schemes. This paper aimed to explore the adoption and success of payment schemes that promote integration of chronic care in European countries. A literature review was used to identify European countries that employed pay-for-coordination (PFC), pay-for-performance (PFP), and bundled payment schemes. Existing evidence from the literature was supplemented with fifteen interviews with chronic care experts in these countries to obtain detailed information regarding the payment schemes, facilitators and barriers to their implementation, and their perceived success. Austria, France, England, the Netherlands, and Germany have implemented payment schemes that were specifically designed to promote the integration of chronic care. Prominent factors facilitating implementation included stakeholder cooperation, adequate financial incentives for stakeholders, and flexible task allocation among different care provider disciplines. Common barriers to implementation included misaligned incentives across stakeholders and gaming. The implemented payment schemes targeted different stakeholders (e.g. individual caregivers, multidisciplinary organizations of caregivers, regions, insurers) in different countries depending on the structure and financing of each health care system. All payment reforms appeared to have changed the structure of chronic care delivery. PFC, as it was implemented in Austria, France and Germany, was perceived to be the most successful in increasing collaboration within and across healthcare sectors, whereas PFP, as it was implemented in England and France, was perceived most successful in improving other indicators of the quality of the care process. Interviewees stated that the impact of the payment reforms on healthcare expenditures remained questionable. The success of a payment scheme depends on the details of the specific implementation in a particular country, but a combination of the schemes may overcome the barriers of each individual scheme.

Alternative level of care: Canada's hospital beds, the evidence and options.

Patients designated as alternative level of care (ALC) are an ongoing concern for healthcare policy makers across Canada. These patients occupy valuable hospital beds and limit access to acute care services. The objective of this paper is to present policy alternatives to address underlying factors associated with ALC bed use. Three alternatives, and their respective limitations and structural challenges, are discussed. Potential solutions may require a mix of policy options proposed here. Inadequate policy jeopardizes new acute care activity-based funding schemes in British Columbia and Ontario. Failure to address this issue could exacerbate pressures on the existing bottlenecks in the community care system in these and other provinces.

Hospital reimbursement incentives: is there a more effective option?--Part II.

As discussed in Part I of this article, hospital executives in Canada, Germany, and the United States manage their facilities' resources to maximize the incentives inherent in their respective reimbursement system and thereby increase their bottom line. It was also discussed that an additional supply of available hospitals, physicians, and other services will generate increased utilization. Part II discusses how the Patient Protection and Affordable Care Act of 2010 will eventually fail since it neither controls prices nor utilization (e.g., imaging, procedures, ambulatory surgery, discretionary spending). This article concludes with the discussion of the German multipayer approach with universal access and global budgets that might well be a model for U.S. healthcare in the future. Although the German healthcare system has a number of shortfalls, its paradigm could offer the most appropriate compromise when selecting the economic incentives to reduce the percentage of the U.S. gross domestic product expenditure for healthcare from 17.4% to roughly 12.0%.

Financial incentives and coverage of child health interventions: a systematic review and meta-analysis.

BACKGROUND: Financial incentives are widely used strategies to alleviate poverty, foster development, and improve health. Cash transfer programs, microcredit, user fee removal policies and voucher schemes that provide direct or indirect monetary incentives to households have been used for decades in Latin America, Sub-Saharan Africa, and more recently in Southeast Asia. Until now, no systematic review of the impact of financial incentives on coverage and uptake of health interventions targeting children under 5 years of age has been conducted. The objective of this review is to provide estimates on the effect of six types of financial incentive programs: (i) Unconditional cash transfers (CT), (ii) Conditional cash transfers (CCT), (iii) Microcredit (MC), (iv) Conditional Microcredit (CMC), (v) Voucher schemes (VS) and (vi) User fee removal (UFR) on the uptake and coverage of health interventions targeting children under the age of five years. METHODS: We conducted systematic searches of a series of databases until September 1st, 2012, to identify relevant studies reporting on the impact of financial incentives on coverage of health interventions and behaviors targeting children under 5 years of age. The quality of the studies was assessed using the CHERG criteria. Meta-analyses were undertaken to estimate the effect when multiple studies meeting our inclusion criteria were available. RESULTS: Our searches resulted in 1671 titles identified 25 studies reporting on the impact of financial incentive programs on 5 groups of coverage indicators: breastfeeding practices (breastfeeding incidence, proportion of children receiving colostrum and early initiation of breastfeeding, exclusive breastfeeding for six months and duration of breastfeeding); vaccination (coverage of full immunization, partial immunization and specific antigens); health care use (seeking healthcare when child was ill, visits to health facilities for preventive reasons, visits to health facilities for any reason, visits for health check-up including growth control); management of diarrhoeal disease (ORS use during diarrhea episode, continued feeding during diarrhea, healthcare during diarrhea episode) and other preventive health interventions (iron supplementation, vitamin A, zinc supplementation, preventive deworming). The quality of evidence on the effect of financial incentives on breastfeeding practices was low but seems to indicate a potential positive impact on receiving colostrum, early initiation of breastfeeding, exclusive breastfeeding and mean duration of exclusive breastfeeding. There is no effect of financial incentives on immunization coverage although there was moderate quality evidence of conditional cash transfers leading to a small but non-significant increase in coverage of age-appropriate immunization. There was low quality evidence of impact of CCT on healthcare use by children under age 5 (Risk difference: 0.14 [95%CI: 0.03; 0.26]) as well as low quality evidence of an effect of user fee removal on use of curative health services (RD=0.62 [0.41; 0.82]). CONCLUSIONS: Financial incentives may have potential to promote increased coverage of several important child health interventions, but the quality of evidence available is low. The more pronounced effects seem to be achieved by programs that directly removed user fees for access to health services. Some indication of effect were also observed for programs that conditioned financial incentives on participation in health education and attendance to health care visits. This finding suggest that the measured effect may be less a consequence of the financial incentive and more due to conditionalities addressing important informational barriers.

Testing payment-for-performance in French acute care hospitals: a point of view from the French Federation of Comprehensive Cancer Centres.

In 2004, France began a diagnosis related groups-based financing system for both public and private acute care hospitals. France opted for a mix of financing systems with over 80% of funding based on diagnosis related groups (DRG). After seven years of DRG-based financing, the French government is testing a payment-for-performance system in acute care hospitals, based on the USA experience. France is currently fine-tuning this model. So far, observations have raised doubts as to whether this approach will improve the value of health care in French hospitals: the budget appears insufficient, the quality of the available indicators is poor and the model is complex. However, it has focused attention on the question of health care quality.

Payment for performance in the Family Health Programme: lessons from the UK Quality and Outcomes Framework / Pagamento para desempenho no Programa Saúde da Família: lições do Quality and Outcomes Framework da Inglaterra

OBJECTIVE: Payment for performance financial incentive schemes reward doctors based on the quality and the outcomes of their treatment. In Brazil, the Ministry of Health is looking to scale up its use in public hospitals and some municipalities are developing payment for performance schemes even for the Family Health Programme. In this article the Quality and Outcomes Framework used in the UK since 2004 is discussed, as well as its experience to elaborate some important lessons that Brazilian municipalities should consider before embarking on payment for performance scheme in primary care settings.

OBJETIVO: Esquemas de pagamento para desempenho recompensam o médico baseado na qualidade e no resultado do tratamento dos seus pacientes. O Ministério da Saúde brasileiro analisa seu uso em hospitais públicos e alguns municípios estão desenvolvendo estratégias de pagamento por desempenho para o Programa de Saúde da Família. No artigo discute-se o Quality and Outcomes Framework - esquema de pagamento para desempenho usado no Reino Unido desde 2004, bem como sua experiência para elaborar algumas lições importantes que os municípios brasileiros devem considerar antes de empreender o esquema de pagamento por desempenho na atenção primária.

Payment for performance in the Family Health Programme: lessons from the UK Quality and Outcomes Framework.

OBJECTIVE: Payment for performance financial incentive schemes reward doctors based on the quality and the outcomes of their treatment. In Brazil, the Ministry of Health is looking to scale up its use in public hospitals and some municipalities are developing payment for performance schemes even for the Family Health Programme. In this article the Quality and Outcomes Framework used in the UK since 2004 is discussed, as well as its experience to elaborate some important lessons that Brazilian municipalities should consider before embarking on payment for performance scheme in primary care settings.

Payment incentives and integrated care delivery: levers for health system reform and cost containment.

The Patient Protection and Affordable Care Act encourages use of payment methods and incentives to promote integrated care delivery models including patient-centered medical homes, accountable care organizations, and primary care and behavioral health integration. These models rely on interdisciplinary provider teams to coordinate patient care; health information and other technologies to assure, monitor, and assess quality, and payment and financial incentives such as bundling, pay-for-performance, and gain-sharing to encourage value-based health care. In this paper, we review evidence about integrated care delivery, payment methods, and financial incentives to improve value in health care purchasing, and address how these approaches can be used to advance health system change.

Aligning physician and hospital incentives: the approach at hospital for special surgery.

Healthcare administrators and physicians alike are navigating an increasingly complex and highly regulated healthcare environment. Unlike in the past, institutions now require strong collaboration among physician and administrative leaders. As providers and managers are trained and work differently, new methods are needed to provide the infrastructure and resources necessary to create, nurture, and sustain alignment between them. We describe four initiatives by administrators and physicians at Hospital for Special Surgery to work together in mutually beneficial relationships that help us achieve the highest level of patient care, satisfaction and safety. These initiatives include improving management efficiency through an orthopaedic service line structure, helping individual physicians grow their practices through the demand-office-operating room initiative of the Physicians Service Department, controlling costs through the supply effectiveness policy, and promoting teamwork in innovation through the technology transfer program.

Aligning incentives in orthopaedics: opportunities and challenges -- the Case Medical Center experience.

For 30 years, the orthopaedic faculty at Case Western Reserve University worked as an independent private corporation within University Hospitals Case Medical Center (Hospital). However, by 2002, it became progressively obvious to our orthopaedic practice that we needed to modify our business model to better manage the healthcare regulatory changes and decreased reimbursement if we were to continue to attract and retain the best and brightest orthopaedic surgeons to our practice. In 2002, our surgeons created a new entity wholly owned by the parent corporation at the Hospital. As part of this transaction, the parties negotiated a balanced employment model designed to fully integrate the orthopaedic surgeons into the integrated delivery system that included the Hospital. This new faculty practice plan adopted a RVU-based compensation model for the physicians, with components that created incentives both for clinical practice and for academic and administrative service contributions. Over the past 5 years, aligning incentives with the Hospital has substantially increased the clinical productivity of the surgeons and has also benefited the Hospital and our patients. Furthermore, aligned incentives between surgeons and hospitals could be of substantial financial benefit to both, as Medicare moves forward with its bundled project initiative.

Economic incentives to promote innovation in healthcare delivery.

Economics influences how medical care is delivered, organized, and progresses. Fee-for-service payment encourages delivery of services. Fee-for-individual-service, however, offers no incentives for clinicians to efficiently organize the care their patients need. Global capitation provides such incentives; it works well in highly integrated practices but not for independent practitioners. The failures of utilization management in the 1990s demonstrated the need for a third alternative to better align incentives, such as bundling payment for an episode of care. Building on Medicare's approach to hospital payment, one can define expanded diagnosis-related groups that include all hospital, physician, and other costs during the stay and appropriate preadmission and postdischarge periods. Physicians and hospitals voluntarily forming a new entity (a care delivery team) would receive such bundled payments along with complete flexibility in allocating the funds. Modifications to gainsharing and antikickback rules, as well as reforms to malpractice liability laws, will facilitate the functioning of the care delivery teams. The implicit financial incentives encourage efficient care for the patient; the episode focus will facilitate measuring patient outcomes. Payment can be based on the resources used by those care delivery teams achieving superior outcomes, thereby fostering innovation improving outcomes and reducing waste.