80 research outputs found
Pay-for-performance for healthcare providers: Design, performance measurement, and (unintended) effects
Healthcare systems around the world are characterized by a suboptimal
delivery of healthcare services. There has been a growing belief among
policymakers that many deficiencies (e.g., in the quality of care) stem
from flawed provider payment systems creating perverse incentives
for healthcare providers. In several countries this has led to reforms
based on pay-for-performance (P4P), a payment approach in which
healthcare providers receive explicit financial incentives to improve the
quality and efficiency of care. Over the past decade, P4P has attracted
widespread interest, with programs being uncritically implemented
in many countries. In contrast to what this interest suggests, however,
to date P4P does not appear to have been very effective in delivering
the desired improvements. Moreover, several unintended effects have
been demonstrated. In part, these disappointing results may well
have been due to the limited knowledge about crucial aspects of the
design and implementation of P4P. By identifying and analyzing these
aspects, synthesizing empirical literature on (unintended) effects of
P4P, and addressing important empirical questions about performance
measurement, this thesis aims to provide insight in key conceptual and
practical issues in the design and implementation of P4P for healthcare
providers
Uitkomstbekostiging in de zorg: een (on)begaanbare weg?
__Abstract__
In veel landen â waaronder Nederland â groeien de zorgkosten sterker dan de economie, schiet de
kwaliteit van zorg op diverse punten tekort, en duidt praktijkvariatie op ruimte voor het verhogen
van de doelmatigheid van zorg. Inadequate bekostigingssystemen en de gebrekkige transparantie van
de kwaliteit van zorg worden vaak genoemd als belangrijke oorzaken van deze problemen. Zo was
een belangrijke conclusie van de recente evaluatie van het zorgstelsel dat het bij zorgaanbieders vaak
nog ontbreekt aan financiële prikkels voor kwaliteit en doelmatigheid
Inkoop huisartsenzorg nog een gok
Verzekeraars willen grip op de kwaliteit die zorgverleners
leveren. De mogelijkheden hiervoor zijn bij huisartsen
veel beperkter dan bij bijvoorbeeld fysiotherapeuten. Er is
behoefte aan objectieve criteria om kwaliteit van zorg in
kaart te brengen
High-risk pooling for mitigating risk selection incentives in health insurance markets with sophisticated risk equalization:an application based on health survey information
Background: Despite sophisticated risk equalization, insurers in regulated health insurance markets still face incentives to attract healthy people and avoid the chronically ill because of predictable differences in profitability between these groups. The traditional approach to mitigate such incentives for risk selection is to improve the risk-equalization model by adding or refining risk adjusters. However, not all potential risk adjusters are appropriate. One example are risk adjusters based on health survey information. Despite its predictiveness of future healthcare spending, such information is generally considered inappropriate for risk equalization, due to feasibility challenges and a potential lack of representativeness. Methods: We study the effects of high-risk pooling (HRP) as a strategy for mitigating risk selection incentives in the presence of sophisticatedâ though imperfectâ risk equalization. We simulate a HRP modality in which insurers can ex-ante assign predictably unprofitable individuals to a âhigh risk poolâ using information from a health survey. We evaluate the effect of five alternative pool sizes based on predicted residual spending post risk equalization on insurersâ incentives for risk selection and cost control, and compare this to the situation without HRP. Results: The results show that HRP based on health survey information can substantially reduce risk selection incentives. For example, eliminating the undercompensation for the top-1% with the highest predicted residual spending reduces selection incentives against the total group with a chronic disease (60% of the population) by approximately 25%. Overall, the selection incentives gradually decrease with a larger pool size. The largest marginal reduction is found moving from no high-risk pool to HRP for the top 1% individuals with the highest predicted residual spending. Conclusion: Our main conclusion is that HRP has the potential to considerably reduce remaining risk selection incentives at the expense of a relatively small reduction of incentives for cost control. The extent to which this can be achieved, however, depends on the design of the high-risk pool.</p
High-risk pooling for mitigating risk selection incentives in health insurance markets with sophisticated risk equalization:an application based on health survey information
Background: Despite sophisticated risk equalization, insurers in regulated health insurance markets still face incentives to attract healthy people and avoid the chronically ill because of predictable differences in profitability between these groups. The traditional approach to mitigate such incentives for risk selection is to improve the risk-equalization model by adding or refining risk adjusters. However, not all potential risk adjusters are appropriate. One example are risk adjusters based on health survey information. Despite its predictiveness of future healthcare spending, such information is generally considered inappropriate for risk equalization, due to feasibility challenges and a potential lack of representativeness. Methods: We study the effects of high-risk pooling (HRP) as a strategy for mitigating risk selection incentives in the presence of sophisticatedâ though imperfectâ risk equalization. We simulate a HRP modality in which insurers can ex-ante assign predictably unprofitable individuals to a âhigh risk poolâ using information from a health survey. We evaluate the effect of five alternative pool sizes based on predicted residual spending post risk equalization on insurersâ incentives for risk selection and cost control, and compare this to the situation without HRP. Results: The results show that HRP based on health survey information can substantially reduce risk selection incentives. For example, eliminating the undercompensation for the top-1% with the highest predicted residual spending reduces selection incentives against the total group with a chronic disease (60% of the population) by approximately 25%. Overall, the selection incentives gradually decrease with a larger pool size. The largest marginal reduction is found moving from no high-risk pool to HRP for the top 1% individuals with the highest predicted residual spending. Conclusion: Our main conclusion is that HRP has the potential to considerably reduce remaining risk selection incentives at the expense of a relatively small reduction of incentives for cost control. The extent to which this can be achieved, however, depends on the design of the high-risk pool.</p
Selection Incentives for Health Insurers in the Presence of Sophisticated Risk Adjustment
This article analyzes selection incentives for insurers in the Dutch basic health
insurance market, which operates with community-rated premiums and sophisticated
risk adjustment. Selection incentives result from the interplay of three market
characteristics: possible actions by insurers, consumer response to these actions, and
predictable variation in profitability of insurance contracts. After a qualitative analysis
of the first two characteristics our prima
Incorporating self-reported health measures in risk equalization through constrained regression
Most health insurance markets with premium-rate restrictions include a risk equalization system to compensate insurers for predictable variation in spending. Recent research has shown, however, that even the most sophisticated risk equalization systems tend to undercompensate (overcompensate) groups of people with poor (good) self-reported health, confronting insurers with incentives for risk selection. Self-reported health measures are generally considered infeasible for use as an explicit ârisk adjusterâ in risk equalization models. This study examines an alternative way to exploit this information, namely through âconstrained regressionâ (CR). To do so, we use administrative data (NÂ =Â 17Â m) and health survey information (NÂ =Â 380Â k) from the Netherlands. We estimate five CR models and compare these models with the actual Dutch risk equalization model of 2016 which was estimated by ordinary least squares (OLS). In the CR models, the estimated coefficients are restricted, such that t
Value-Based Provider Payment Initiatives Combining Global Payments With Explicit Quality Incentives
An essential element in the pursuit of value-based health care is provider payment reform. This article aims to identify and analyze payment initiatives comprising a specific manifestation of value-based payment reform that can be expected to contribute to value in a broad sense: (a) global base payments combined with (b) explicit quality incentives. We conducted a systematic review of the literature, consulting four scientific bibliographic databases, reference lists, the Internet, and experts. We included and compared 18 initiatives described in 111 articles/documents on key design features and impact on value. The initiatives are heterogeneous regarding the operationalization of the two payment components and associated design features. Main commonalities between initiatives are a strong emphasis on primary care, the use of âvirtualâ spending targets, and the application of risk adjustment and other risk-mitigating measures. Evaluated initiatives generally show promising results in terms of lower spending growth with equal or improved quality
Identifying prognostic factors for clinical outcomes and costs in four high-volume surgical treatments using routinely collected hospital data
Identifying prognostic factors (PFs) is often costly and labor-intensive. Routinely collected hospital data provide opportunities to identify clinically relevant PFs and construct accurate prognostic models without additional data-collection costs. This multicenter (66 hospitals) study reports on associations various patient-level variables have with outcomes and costs. Outcomes were in-hospital mortality, intensive care unit (ICU) admission, length of stay, 30-day readmission, 30-day reintervention and in-hospital costs. Candidate PFs were age, sex, Elixhauser Comorbidity Score, prior hospitalizations, prior days spent in hospital, and socio-economic status. Included patients dealt with either colorectal carcinoma (CRC, n = 10,254), urinary bladder carcinoma (UBC, n = 17,385), acute percutaneous coronary intervention (aPCI, n = 25,818), or total knee arthroplasty (TKA, n = 39,214). Prior hospitalization significantly increased readmission risk in all treatments (OR between 2.15 and 25.50), whereas prior days spent in hospital decreased this risk (OR between 0.55 and 0.95). In CRC patients, women had lower risk of in-hospital mortality (OR 0.64), ICU admittance (OR 0.68) and 30-day reintervention (OR 0.70). Prior hospitalization was the strongest PF for higher costs across all treatments (31â64% costs increase/hospitalization). Prognostic model performance (c-statistic) ranged 0.67â0.92, with Brier scores below 0.08. R-squared ranged from 0.06â0.19 for LoS and 0.19â0.38 for costs. Identified PFs should be considered as building blocks for treatment-specific prognostic models and information for monitoring patients after surgery. Researchers and clinicians might benefit from gaining a better insight into the drivers behind (costs) prognosis
Value-based provider payment: Towards a theoretically preferred design
Worldwide, policymakers and purchasers are exploring innovative provider payment strategies promoting value in health care, known as value-based payments (VBP). What is meant by 'value', however, is often unclear and the relationship between value and the payment design is not explicated. This paper aims at
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