A scoping review of alternative payment models in maternity care: insights in key design elements and effects on health and spending

Introduction: Although effects of alternative payment models on health outcomes and health spending are unclear, they are increasingly implemented in maternity care. We aimed to provide an overview of alternative payment models implemented in maternity care, describing their key design elements among which the type of APM, the care providers that participate in the model, populations and care services that are included and the applied risk mitigation strategies. Next to that, we made an inventory of the empirical evidence on the effects of APMs on maternal and neonatal health outcomes and spending on maternity care.Methods: We searched PubMed, Embase and Scopus databases for articles published from January 2007 through October 2020. Search key words included 'alternative payment model', 'value based payment model', 'obstetric', 'maternity'. English or Dutch language articles were included if they described or empirically evaluated initiatives implementing alternative payment models in maternity care in high-income countries. Additional relevant documents were identified through reference tracking. We systematically analyzed the initiatives found and examined the evidence regarding health outcomes and health spending. The process was guided by the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) to ensure validity and reliability.Results: We identified 17 initiatives that implemented alternative payment models in maternity care. Thirteen in the United States, two in the United Kingdom, one in New Zealand and one in the Netherlands. Within these initiatives three types of alternative payment models were implemented; pay-for-performance (n = 2), shared savings models (n = 7) and bundled payment models (n = 8). Alternative payment models that shifted more financial accountability towards providers seemed to include more strategies that mitigated those risks. Risk mitigation strategies were applied to the included population, included services or at the level of total expenditures. Of these seventeen initiatives, we found four empirical effect studies published in peer-reviewed journals. Three of them were of moderate quality and one weak. Two studies described an association of the alternative payment model with an improvement of specific health outcomes and two studies described a reduction in medical spending.Conclusions: This study shows that key design elements of alternative payment models including risk mitigation strategies vary highly. Risk mitigation strategies seem to be relevant tools to increase APM uptake and protect providers from (initially) bearing too much (perceived) financial risk. Empirical evidence on the effects of APMs on health outcomes and spending is still limited. A clear definition of key design elements and a further, indepth, understanding of key design elements and how they operate into different health settings is required to shape payment reform that aligns with its goals.Prevention, Population and Disease management (PrePoD)Public Health and primary car

Combining satellite data and community-based observations for forest monitoring

Within the Reducing Emissions from Deforestation and Degradation (REDD+) framework, the involvement of local communities in national forest monitoring activities has the potential to enhance monitoring efficiency at lower costs while simultaneously promoting transparency and better forest management. We assessed the consistency of forest monitoring data (mostly activity data related to forest change) collected by local experts in the UNESCO Kafa Biosphere Reserve, Ethiopia. Professional ground measurements and high resolution satellite images were used as validation data to assess over 700 forest change observations collected by the local experts. Furthermore, we examined the complementary use of local datasets and remote sensing by assessing spatial, temporal and thematic data quality factors. Based on this complementarity, we propose a framework to integrate local expert monitoring data with satellite-based monitoring data into a National Forest Monitoring System (NFMS) in support of REDD+ Measuring, Reporting and Verifying (MRV) and near real-time forest change monitoring

The Knight of Malta

BACKGROUND: For most women, participation in decision-making during maternity care has a positive impact on their childbirth experiences. Shared decision-making (SDM) is widely advocated as a way to support people in their healthcare choices. The aim of this study was to identify quality criteria and professional competencies for applying shared decision-making in maternity care. We focused on decision-making in everyday maternity care practice for healthy women. METHODS: An international three-round web-based Delphi study was conducted. The Delphi panel included international experts in SDM and in maternity care: mostly midwives, and additionally obstetricians, educators, researchers, policy makers and representatives of care users. Round 1 contained open-ended questions to explore relevant ingredients for SDM in maternity care and to identify the competencies needed for this. In rounds 2 and 3, experts rated statements on quality criteria and competencies on a 1 to 7 Likert-scale. A priori, positive consensus was defined as 70% or more of the experts scoring >/=6 (70% panel agreement). RESULTS: Consensus was reached on 45 quality criteria statements and 4 competency statements. SDM in maternity care is a dynamic process that starts in antenatal care and ends after birth. Experts agreed that the regular visits during pregnancy offer opportunities to build a relationship, anticipate situations and revisit complex decisions. Professionals need to prepare women antenatally for unexpected, urgent decisions in birth and revisit these decisions postnatally. Open and respectful communication between women and care professionals is essential; information needs to be accurate, evidence-based and understandable to women. Experts were divided about the contribution of professional advice in shared decision-making and about the partner's role. CONCLUSIONS: SDM in maternity care is a dynamic process that takes into consideration women's individual needs and the context of the pregnancy or birth. The identified ingredients for good quality SDM will help practitioners to apply SDM in practice and educators to prepare (future) professionals for SDM, contributing to women's positive birth experience and satisfaction with care

The dog as an animal model for DISH?

Diffuse idiopathic skeletal hyperostosis (DISH) is a systemic disorder of the axial and peripheral skeleton in humans and has incidentally been described in dogs. The aims of this retrospective radiographic cohort study were to determine the prevalence of DISH in an outpatient population of skeletally mature dogs and to investigate if dogs can be used as an animal model for DISH. The overall prevalence of canine DISH was 3.8% (78/2041). The prevalence of DISH increased with age and was more frequent in male dogs, similar to findings in human studies. In the Boxer breed the prevalence of DISH was 40.6% (28/69). Dog breeds represent closed gene pools with a high degree of familiar relationship and the high prevalence in the Boxer may be indicative of a genetic origin of DISH. It is concluded that the Boxer breed may serve as an animal model for DISH in humans

Assessing the performance of maternity care in Europe: A critical exploration of tools and indicators

Background: This paper critically reviews published tools and indicators currently used to measure maternity care performance within Europe, focusing particularly on whether and how current approaches enable systematic appraisal of processes of minimal (or non-) intervention in support of physiological or "normal birth". The work formed part of COST Actions IS0907: "Childbirth Cultures, Concerns, and Consequences: Creating a dynamic EU framework for optimal maternity care" (2011-2014) and IS1405: Building Intrapartum Research Through Health - an interdisciplinary whole system approach to understanding and contextualising physiological labour and birth (BIRTH) (2014-). The Actions included the sharing of country experiences with the aim of promoting salutogenic approaches to maternity care. Methods: A structured literature search was conducted of material published between 2005 and 2013, incorporating research databases, published documents in english in peer-reviewed international journals and indicator databases which measured aspects of health care at a national and pan-national level. Given its emergence from two COST Actions the work, inevitably, focused on Europe, but findings may be relevant to other countries and regions. Results: A total of 388 indicators were identified, as well as seven tools specifically designed for capturing aspects of maternity care. Intrapartum care was the most frequently measured feature, through the application of process and outcome indicators. Postnatal and neonatal care of mother and baby were the least appraised areas. An over-riding focus on the quantification of technical intervention and adverse or undesirable outcomes was identified. Vaginal birth (no instruments) was occasionally cited as an indicator; besides this measurement few of the 388 indicators were found to be assessing non-intervention or "good" or positive outcomes more generally. Conclusions: The tools and indicators identified largely enable measurement of technical interventions and undesirable health (or pathological medical) outcomes. A physiological birth generally necessitates few, or no, interventions, yet most of the indicators presently applied fail to capture (a) this phenomenon, and (b) the relationship between different forms and processes of care, mode of birth and good or positive outcomes. A need was identified for indicators which capture non-intervention, reflecting the reality that most births are low-risk, requiring few, if any, technical medical procedures

Toward bundled payment for birth care

alleen digitaal verschenenNaar aanleiding van relatief hoge sterftecijfers rond de geboorte in Nederland zijn de afgelopen jaren tal van maatregelen genomen om de kwaliteit van de geboortezorg en de samenwerking tussen de verschillende zorgverleners te verbeteren. Om die samenwerking verder te verbeteren, wordt nu ook de bekostiging onder de loep genomen. Het ministerie van VWS heeft besloten dat de verschillende onderdelen van de geboortezorg (verloskundigen, gynaecologen en kraamzorg) vanaf 2017 worden samengevoegd in één integraal tarief. Nu worden deze nog apart bekostigd. Het integrale tarief vraagt ook om organisatorische veranderingen, waaronder de vorming van een geboortezorgorganisatie, waar de betrokken partijen zich nu op aan het voorbereiden zijn. Uit interviews met het RIVM blijkt dat betrokken partijen daarbij zowel kansen ervaren om de zorg te verbeteren, als spanningen en onzekerheden, bijvoorbeeld over hun autonomie. Momenteel wordt in regionale overlegvormen, de zogenoemde Verloskundige Samenwerkingsverbanden (VSV's), besproken hoe deze geboortezorgorganisaties kunnen worden vormgegeven en wat de rol van de verschillende zorgaanbieders daarin is. Dit blijkt een complex vraagstuk waarbij (tegengestelde) belangen naar voren komen, zoals de gevolgen van een eventuele herschikking van taken. Partijen geven aan dat hiervoor specifieke kennis nodig is op organisatorisch, fiscaal en financieel vlak, die nu veelal ontbreekt. Dit gebrek aan kennis leidt tot onzekerheid over de (financiële) consequenties van verschillende organisatievormen. Deze onzekerheid wordt versterkt doordat bijvoorbeeld de landelijke vormgeving van integrale bekostiging (nog) ontbreekt. Het ontbreken van een geautoriseerde zorgstandaard en een verschil in zorginkoopbeleid tussen zorgverzekeraars draagt bij aan deze onzekerheid. Het RIVM monitort de komende jaren in opdracht van het ministerie van VWS de overgang naar integrale bekostiging in de geboortezorg. In 2018 zal een eindrapportage worden opgesteld. In de tussenliggende periode zal blijken in hoeverre daadwerkelijk contracten op basis van integrale bekostiging kunnen worden afgesloten en wat het effect daarvan is op de samenwerking in en de kwaliteit, toegankelijkheid en betaalbaarheid van de geboortezorg.In recent years, various policies have been implemented to improve quality of birth care and collaboration between birth care providers in order to lower the relatively high mortality rates in the Netherlands. In 2017, the Dutch Ministry of Health, Welfare and Sport will introduce a payment reform in order to enhance the collaboration further between different providers. This payment reform consists of a bundled payment including all care services delivered by midwifes, gynecologists and maternity care providers. Currently, these providers are paid on a fee-for-service basis. Most providers, as they prepare for this payment reform, mentioned during interviews that they see opportunities, but also threats and uncertainties, for instance regarding their autonomy. Within regional obstetrical collaborative, providers are discussing how to govern a provider-led entity, which will serve as a general contractor of the bundled payment contract. This discussion appears to be complex due to conflicting interests between the involved providers, and requires specific knowledge with respect to governance, finance and tax laws. Most providers lack this specific knowledge, which in turn leads to uncertainties among providers regarding the (financial) consequences of the potential organization models. Unclarity about the design of the bundled payment, the lack of a broadly agreed on care standard for birth care, and a difference in purchasing policies between insurers increase these uncertainties. In the next coming years, the National Institute for Public Health and the Environment will monitor the transition toward a bundled payment model for birth care. A final report will be published in 2018. Till then, it needs to be seen whether bundled payment contracts will be signed, and what their impact is on the provider's collaboration and the quality, accessibility and affordability of birth care.Ministerie van VW

National ambulance plan for distribution and availability of ambulance care 2020

Het RIVM heeft berekend hoeveel ambulances er in Nederland in 2020 nodig zijn. Op werkdagen overdag zijn dat er 642, 20 meer dan vorig jaar is berekend. De belangrijkste verklaring voor de extra 20 ambulances is dat er meer standplaatsen nodig zijn. Er zijn meer standplaatsen nodig doordat de uitgangspunten van het rekenmodel zijn aangepast. Verder zijn door de bijgestelde uitgangspunten ook extra ambulances toebedeeld aan regio's waar de werkdruk erg hoog is. Een derde verklaring is dat er in 2019 meer ritten zijn gereden; het aantal ritten in het jaar ervoor wordt gebruikt in het rekenmodel. Het 'referentiekader spreiding en beschikbaarheid ambulancezorg' berekent het aantal ambulances waarmee de ambulancezorg in Nederland kan worden uitgevoerd. Dit model is gebaseerd op een aantal uitgangspunten voor de Nederlandse ambulancezorg. Voorbeelden zijn de tijd na een melding waarbinnen een ambulance ter plaatse moet zijn en de spreiding van de standplaatsen over het land. Het model is dit jaar aangepast om de 25 Regionale Ambulance Voorzieningen (RAV's) in Nederland vergelijkbare randvoorwaarden te geven voor de spreiding en capaciteit. Het ministerie van VWS, de Ambulancezorg Nederland (AZN) en Zorgverzekeraars Nederland (ZN) hebben de uitgangspunten bijgesteld. De minister voor Medische Zorg en Sport heeft het nieuwe referentiekader vastgesteld. De Nederlandse Zorgautoriteit (NZa) gebruikt de uitkomsten om te bepalen hoe de kosten van de ambulancezorg gedekt zullen worden.RIVM has calculated how many ambulances will be needed in the Netherlands in 2020. On working days in the daytime, the number needed is 642, which is 20 more than was calculated last year. The most important reason for the extra 20 ambulances is that there are more ambulance stations needed. That is because the preconditions of the calculation model have been modified. Due to the modified preconditions, extra ambulances have also been assigned to regions where the workload is very high. A third reason for the increase is that more services was provided in 2019; the calculation model uses the number of services in the preceding year. The 'National ambulance plan' for the distribution and availability of ambulance care' calculates the number of ambulances needed to provide ambulance care services in the Netherlands. This model is based on a number of preconditions regarding ambulance care in the Netherlands. Examples of this include ambulance response time - in other words the maximum amount of time that may elapse between the receipt of a request for ambulance support and the arrival of an ambulance at the place in question - as well as the distribution of the ambulance stations throughout the country. The model was modified this year in order to guarantee a level playing field for the 25 Regional Ambulance Facilities in the Netherlands with regard to ambulance distribution and capacity. The Dutch Ministry of Health, Welfare and Sport, Ambulance Care Netherlands (AZN), and the Association of Dutch Health Insurers (ZN) have modified the model specifications. The Minister for Medical Care and Sport has approved the new reference framework. The Dutch Healthcare Authority (NZa) uses the results of the model to determine how the costs of the ambulance care will be covered.Ministerie van VW

Supply and accessibility of emergency hospital care in the Netherlands 2017 : Analysis of the geographical accessibility of hospitals

Het RIVM heeft het aanbod en de bereikbaarheid geïnventariseerd van de ziekenhuizen in Nederland die in april 2017 spoedeisende hulp aanboden. Dit is ook voor de acute verloskunde gedaan. Uit de modelberekeningen blijkt dat deze ziekenhuizen zodanig over Nederland zijn verspreid dat 99,8 procent van de inwoners binnen 45 minuten naar een spoedeisende hulpafdeling (SEH) of een ziekenhuis met acute verloskunde kunnen worden vervoerd. In april 2017 waren er 89 SEH's met 24/7-uurs openingstijden. Dat is één minder dan in 2016 en twee minder dan in 2014. Op 81 ziekenhuislocaties werd 24/7-uur per week acute verloskunde aangeboden. Dat is evenveel als in 2016 en drie minder dan in 2014. In de inventarisatie zijn de locaties van ambulancestandplaatsen ook geactualiseerd. Sinds de laatste actualisatie in 2013 zijn er dertien standplaatsen bijgekomen en zijn sommige standplaatsen verhuisd. In deze bereikbaarheidsanalyse wordt gekeken naar de spreiding van ziekenhuizen over Nederland. De analyse bepaalt hoeveel ziekenhuizen als 'gevoelig' worden aangemerkt. Er zijn nu tien gevoelige ziekenhuizen met een 24/7-uurs basis-SEH. Wat acute verloskunde betreft zijn er twaalf gevoelige ziekenhuizen. Een ziekenhuis wordt zo genoemd als het aantal bewoners dat volgens het bereikbaarheidsmodel niet binnen 45 minuten naar een SEH kan worden gebracht toeneemt wanneer dit ziekenhuis sluit. De duur van de rit wordt berekend op basis van de tijd die de ambulance nodig heeft om van de standplaats, via het woonadres van de patiënt naar het ziekenhuis te komen. Deze modelmatige ritduur wordt vervolgens vergeleken met de spreidingsnorm van 45-minuten. In dit onderzoek is ook de aanwezigheid en beschikbaarheid geïnventariseerd van onder meer specialisten, verpleegkundigen en faciliteiten om op de SEH's diagnoses te stellen en behandelingen te starten. Daarnaast is gekeken naar de samenwerking tussen SEH's en huisartsenposten (HAP's). In 42 gevallen waren de 24/7-uurs SEH en HAP geïntegreerd, met een gezamenlijke ingang en een procedure voor mensen die zelf naar spoedeisende hulp komen met minder urgente/complexe klachten.RIVM surveyed the supply and accessibility of hospitals in the Netherlands that provided emergency care in April 2017. This was also done for acute obstetrics. The results show that these hospitals are spread across the Netherlands in such a way that 99.8 percent of the residents can be transported to an emergency medical department (A&E) or hospital with acute obstetrics within 45 minutes, according to the accessibility model. In April 2017, there were 89 A&Es that were open 24/7. That is one less than in 2016 and two less than in 2014. Acute obstetrics was provided 24/7 at 81 hospital locations. That is the same as in 2016 and three less than in 2014. The locations of ambulance stations were also updated in the inventory. Since the last update in 2013, thirteen ambulance stations were added and some stations were relocated. This accessibility analysis looked at the distribution of hospitals throughout the Netherlands. The analysis determines how many hospitals are considered 'sensitive'. There are now ten sensitive hospitals with a 24/7 basic A&E. The accessibility analysis for acute obstetrics results in twelve sensitive hospitals. A hospital is designated as such if, according to the theoretic model, the number of residents that may take more than 45 minutes to be brought to an A&E increases when this hospital closes. The duration of the ride is calculated based on the time the ambulance requires to get from the station via the patient's residence to the hospital. This model-based ride time is then compared with the 45-minute distribution standard. This study also examined the presence and accessibility of, among others, specialists, nurses and facilities to make the diagnoses at the A&Es and start treatment. The collaboration between the A&Es and the out-of-hours GP services was also examined. In 42 cases, the 24/7 A&E and out-of-hours GP services were integrated, with a joint entrance and a procedure for people who report for emergency care with less urgent/complex complaints on their own initiative.Ministerie van VW