Hospital response to Activity-Based Funding and price incentives: evidence from Ireland

Activity-Based Funding (ABF) is a funding policy incentivising hospitals to deliver more efficient care. ABF can be complemented by additional price incentives to further drive hospital efficiency. In 2016, ABF was introduced for public patients admitted to Irish public hospitals. Additionally, a price incentive to perform laparoscopic cholecystectomy as day-case surgery was introduced in 2018. Private patient activity in public hospitals was subject to neither ABF nor price incentive. Using national Hospital In-Patient-Enquiry activity data 2013–2019, we evaluated the impact of ABF and the price incentive for laparoscopic cholecystectomy surgery in Ireland. We exploit variation in hospital payment for public and private patients treated in public acute Irish hospitals and employ a Propensity Score Matching Difference-in-Differences approach. We estimate the funding change impacts across outcomes measuring the proportion of day-case admissions and length of stay. We found no significant impact for either outcomes linked to ABF introduction. Similarly, no impacts linked to the price incentive were observed. It appears providers of laparoscopic cholecystectomy in Irish public hospitals did not react to the new funding mechanisms. The implementation of the funding policies did not improve hospital efficiency. Further strengthening of these new funding mechanisms are required to deliver more efficient care.</p

A comparison of four quasi-experimental methods: an analysis of the introduction of activity-based funding in Ireland

Background: Health services research often relies on quasi-experimental study designs in the estimation of treatment effects of a policy change or an intervention. The aim of this study is to compare some of the commonly used non-experimental methods in estimating intervention effects, and to highlight their relative strengths and weaknesses. We estimate the effects of Activity-Based Funding, a hospital financing reform of Irish public hospitals, introduced in 2016. Methods: We estimate and compare four analytical methods: Interrupted time series analysis, Difference-in-Differences, Propensity Score Matching Difference-in-Differences and the Synthetic Control method. Specifically, we focus on the comparison between the control-treatment methods and the non-control-treatment approach, interrupted time series analysis. Our empirical example evaluated the length of stay impact post hip replacement surgery, following the introduction of Activity-Based Funding in Ireland. We also contribute to the very limited research reporting the impacts of Activity-Based-Funding within the Irish context. Results: Interrupted time-series analysis produced statistically significant results different in interpretation, while the Difference-in-Differences, Propensity Score Matching Difference-in-Differences and Synthetic Control methods incorporating control groups, suggested no statistically significant intervention effect, on patient length of stay. Conclusion: Our analysis confirms that different analytical methods for estimating intervention effects provide different assessments of the intervention effects. It is crucial that researchers employ appropriate designs which incorporate a counterfactual framework. Such methods tend to be more robust and provide a stronger basis for evidence-based policy-making.</p

Analytical methods to assess the impacts of activity-based funding (ABF): a scoping review

Background: Activity-Based Funding (ABF) has been implemented across many countries as a means to incentivise efficient hospital care delivery and resource use. Previous reviews have assessed the impact of ABF implementation on a range of outcomes across health systems. However, no comprehensive review of the methods used to generate this evidence has been undertaken. The aim of this review is to identify and assess the analytical methods employed in research on ABF hospital performance outcomes. Methods: We conducted a scoping review in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews. Five academic databases and reference lists of included studies were used to identify studies assessing the impact of ABF on hospital performance outcomes. Peer-reviewed quantitative studies published between 2000 and 2019 considering ABF implementation outside the U.S. were included. Qualitative studies, policy discussions and commentaries were excluded. Abstracts and full text studies were double screened to ensure consistency. All analytical approaches and their relative strengths and weaknesses were charted and summarised. Results: We identified 19 studies that assessed hospital performance outcomes from introduction of ABF in England, Korea, Norway, Portugal, Israel, the Netherlands, Canada, Italy, Japan, Belgium, China, and Austria. Quasi-experimental methods were used across most reviewed studies. The most commonly used assessment methods were different forms of interrupted time series analyses. Few studies used difference-in-differences or similar methods to compare outcome changes over time relative to comparator groups. The main hospital performance outcome measures examined were case numbers, length of stay, mortality and readmission. Conclusions: Non-experimental study designs continue to be the most widely used method in the assessment of ABF impacts. Quasi-experimental approaches examining the impact of ABF implementation on outcomes relative to comparator groups not subject to the reform should be applied where possible to facilitate identification of effects. These approaches provide a more robust evidence-base for informing future financing reform and policy.</p

Predictors of career progression and obstacles and opportunities for non-EU hospital doctors to undertake postgraduate training in Ireland

Background The World Health Organization’s Global Code on the International Recruitment of Health Personnel urges Member States to observe fair recruitment practices and ensure equality of treatment of migrant and domestically-trained health personnel. However, international medical graduates (IMGs) have experienced difficulties in accessing postgraduate training and in progressing their careers in several destination countries. Ireland is highly dependent on IMGs, but also employs non-European Union (EU) doctors who qualified as doctors in Ireland. However, little is known regarding the career progression of these doctors. In this context, the present study assesses the determinants of career progression of non-EU doctors with particular focus on whether barriers to progression exist for those graduating outside Ireland compared to those who have graduated within. Methods The study utilises quantitative data from an online survey of non-EU doctors registered with the Medical Council of Ireland undertaken as part of the Doctor Migration Project (2011–2013). Non-EU doctors registered with the Medical Council of Ireland were asked to complete an online survey about their recruitment, training and career experiences in Ireland. Analysis was conducted on the responses of 231 non-EU hospital doctors whose first post in Ireland was not permanent. Career progression was analysed by means of binary logistic regression analysis. Results While some of the IMGs had succeeded in accessing specialist training, many experienced slow or stagnant career progression when compared with Irish-trained non-EU doctors. Key predictors of career progression for non-EU doctors working in Ireland showed that doctors who qualified outside of Ireland were less likely than Irish-trained non-EU doctors to experience career progression. Length of stay as a qualified doctor in Ireland was strongly associated with career progression. Those working in anaesthesia were significantly more likely to experience career progression than those in other specialities. Conclusions The present study highlights differences in terms of achieving career progression and training for Irish-trained non-EU doctors, compared to those trained elsewhere. However, the findings herein warrant further attention from a workforce planning and policy development perspective regarding Ireland’s obligations under the Global Code of hiring, promoting and remunerating migrant health personnel on the basis of equality of treatment with the domestically-trained health workforce.</p