Confronting evidence: individualised care and the case for shared decision-making.

In many clinical scenarios there exists more than one clinically appropriate intervention strategy. When these involve subjective trade-offs between potential benefits and harms, patients\u27 preferences should inform decision-making. Shared decision-making is a collaborative process, where clinician and patient reconcile the best available evidence with respect for patients\u27 individualized care preferences. In practice, clinicians may be poorly equipped to participate in this process. Shared decision-making is applicable to many conditions including stable coronary artery disease, end-of-life care, and numerous small decisions in chronic disease management. There is evidence of more clinically appropriate care patterns, improved patient understanding and sense of empowerment. Many trials reported a 20% reduction in major surgery in favour of conservative treatment, although demand tends to increase for some interventions. The generalizability of international evidence to Ireland is unclear. Considering the potential benefits, there is a case for implementing and evaluating shared decision-making pilot projects in Ireland

Optimisation of Healthcare Contracts: Tensions Between Standardisation and Innovation Comment on “Competition in Healthcare: Good, Bad or Ugly?”

An important determinant of health system performance is contracting. Providers often respond to financial incentives, despite the ethical underpinnings of medicine, and payers can craft contracts to influence performance. Yet contracting is highly imperfect in both single-payer and multi-payer health systems. Arguably, in a competitive, multi-payer environment, contractual innovation may occur more rapidly than in a single-payer system. This innovation in contract design could enhance performance. However, contractual innovation often fails to improve performance as payer incentives are misaligned with public policy objectives. Numerous countries seek to improve healthcare contracts, but thus far no health system has demonstrably crafted the necessary blend of incentives to stimulate optimal contractin

"Managed competition" for Ireland? The single versus multiple payer debate.

Background A persistent feature of international health policy debate is whether a single-payer or multiple-payer system can offer superior performance. In Ireland, a major reform proposal is the introduction of ?managed competition? based on the recent reforms in the Netherlands, which would replace many functions of Ireland?s public payer with a system of competing health insurers from 2016. This article debates whether Ireland meets the preconditions for effective managed competition, and whether the government should implement the reform according to its stated timeline. We support our arguments by discussing the functioning of the Dutch and Irish systems. Discussion Although Ireland currently lacks key preconditions for effective implementation, the Dutch experience demonstrates that some of these can be implemented over time, such as a more rigorous risk equalization system. A fundamental problem may be Ireland?s sparse hospital distribution. This may increase the market power of hospitals and weaken insurers? ability to exclude inefficient or poor quality hospitals from contracts, leading to unwarranted spending growth. To mitigate this, the government proposes to introduce a system of price caps for hospital services. The Dutch system of competition is still in transition and it is premature to judge its success. The new system may have catalyzed increased transparency regarding clinical performance, but outcome measurement remains crude. A multi-payer environment creates some disincentives for quality improvement, one of which is free-riding by insurers on their rivals? quality investments. If a Dutch insurer invests in improving hospital quality, hospitals will probably offer equivalent quality to consumers enrolled with other insurance companies. This enhances equity, but may weaken incentives for improvement. Consequently the Irish government, rather than insurers, may need to assume responsibility for investing in clinical quality. Plans are in place to assure consumers of free choice of insurer, but a key concern is a potential shortfall of institutional capacity to regulate managed competition. Summary Managed competition requires a long transition period and the requisite preconditions are not yet in place. The Irish government should refrain from introducing managed competition until sufficient preconditions are in place to allow effective performance

Optimisation of Healthcare Contracts: Tensions Between Standardisation and Innovation Comment on "Competition in Healthcare: Good, Bad or Ugly?".

An important determinant of health system performance is contracting. Providers often respond to financial incentives, despite the ethical underpinnings of medicine, and payers can craft contracts to influence performance. Yet contracting is highly imperfect in both single-payer and multi-payer health systems. Arguably, in a competitive, multi-payer environment, contractual innovation may occur more rapidly than in a single-payer system. This innovation in contract design could enhance performance. However, contractual innovation often fails to improve performance as payer incentives are misaligned with public policy objectives. Numerous countries seek to improve healthcare contracts, but thus far no health system has demonstrably crafted the necessary blend of incentives to stimulate optimal contracting

Changing the mix of healthcare providers : impact on price, efficiency and quality

THESIS 10871Service providers, the personnel and organisations that deliver care, are the foundation of any health care system. The personnel include not only doctors, but pharmacists, nurses, and an array of allied health professions, while the organisations include hospitals, pharmacies, and ambulatory surgery centres. The configuration of providers influences dimensions of performance such as access, clinical quality, and value

Optimisation of Healthcare Contracts: Tensions Between Standardisation and Innovation; Comment on “Competition in Healthcare: Good, Bad or Ugly?”

An important determinant of health system performance is contracting. Providers often respond to financial incentives, despite the ethical underpinnings of medicine, and payers can craft contracts to influence performance. Yet contracting is highly imperfect in both single-payer and multi-payer health systems. Arguably, in a competitive, multi-payer environment, contractual innovation may occur more rapidly than in a single-payer system. This innovation in contract design could enhance performance. However, contractual innovation often fails to improve performance as payer incentives are misaligned with public policy objectives. Numerous countries seek to improve healthcare contracts, but thus far no health system has demonstrably crafted the necessary blend of incentives to stimulate optimal contracting

A cost and outcomes analysis of alternative models of care for young children with severe disabilities in Ireland

AbstractYoung children born with severe disabilities in Ireland may receive either continuous hospital inpatient care or homecare services in their family environment. In practice, a charitable body – the Jack and Jill Foundation (JJF) – is the predominant provider of homecare. This non-statutory homecare service is often supplemented by statutory homecare services, through Primary Community and Continuing Care teams. The purposes of this exploratory study are twofold: firstly, we compare costs (both direct and indirect) associated with hospital inpatient care and JJF homecare; secondly, we compare levels of family satisfaction for recipients of continuous hospital inpatient care, JJF homecare and statutory homecare services. Direct costs appear to be substantially greater for the hospital inpatient model than for JJF homecare, from the perspective of both the health service (€156,282 versus €16,267) and of families (€22,261 versus €2,620). Indirect productivity costs are more closely matched at €27,728 for the hospital inpatient model and €22,941 for JJF homecare. Satisfaction ratings were greatest for JJF, with a mean rating of 4.89 out of 5, compared to 3.28 for inpatient hospital care, and just 2.86 for statutory homecare services. Findings support previous research that the homecare model is likely to be cost-effective, with lower costs falling on both providers and on families. In addition, families expressed a clear preference for care to be provided at home