Can we improve the health system with pay-for-performance?

Advanced healthcare systems are moving toward greater efficiency, transparency and accountability, and this trend is not likely to change There is no single measure that will improve service delivery and patient outcomes, ensure financial sustainability and increase accountability and transparency in a health system The jury is still out on whether financial incentive mechanisms, such as pay-for-performance, work as intended and deliver value for money The research literature is rich in lessons policymakers need to keep in mind when developing and rolling out pay-for-performance programs: Program design Build on what already exists Formulate a clear business case that defines the objectives of the program in terms of the desired outcomes Define performance using absolute and relative thresholds, ensure target can be adjusted over time and attribute credit for performance to participants in ways that foster care across serviced populations and not on a case-by-case basis Ensure methodologies for risk adjustment are developed prior to the program’s introduction Model and evaluate the program carefully before implementation and at regular intervals afterward. Pilot the program before rolling it out in a phased approach Consider regional disparities when modelling and evaluating the program prior and post implementation Design the program to drive improvement and quality across a range of service providers performing at various levels and not just reward current high performers Performance targets must be perceived as being achievable although not without some additional effort Allow room for innovation and flexibility Data collection Ensure strong health information systems are in place Use rigorous and verifiable data collection methods and analysis, allow for health service providers to review/correct/supplement data and determine rewards using long-term data trends Incentives Incentives should be sufficient, equitable and transparent in order to have any effect Incentives should reach various levels within an organisation Financial incentives are more likely to have the intended effect where there is one single funder Stakeholders Secure strong political and management support Design the program collaboratively with health service providers and professional health associations and organisation Keep in mind Pay-for-performance can yield small gains at large costs, particularly when targets are set in the absence of a good baseline Potential perverse and unintended consequences need to be carefully considered Not everything can be measured. Current pay-for-performance programs focus on clinical and organisational measures, which may be relatively easy to measure through objective data or observation, but there are other aspects that are less easily quantified and are only briefly considered in many pay-for-performance programs such as: continuity of care, ease of access to care, strength of the patient-doctor relationship and patient satisfaction Beyond pay-for-performance Payment systems and financial incentive programs cannot do everything. Many of their key objectives, such as lowering costs, improving quality and driving appropriate change, are goals that are achievable in concert with other policy initiatives Invest in outcomes and health service researc

Can we improve the health system with performance reporting?

Advanced healthcare systems are moving toward greater efficiency, transparency and accountability, and this trend will continue, particularly in fiscally-constrained environments There is no single measure that will improve service delivery and patient outcomes, ensure financial sustainability and increase accountability and transparency in a health system Performance reporting in healthcare will work if properly developed and implemented keeping the following twelve lessons in mind: Program design Understand the social, political and economic considerations carefully before setting targets, monitoring performance and reporting on them Strive for mandatory, system-wide participation Allow health providers and organisations to drive improvements in a devolved manner, which are patient-centred Strive for more than just wait-time measures—such measures could include re-admission rates, ward infection rates and in-hospital death rates Include both public and non-public performance reporting mechanisms Be mindful of minimising dysfunctional, unintended consequences Always pilot before rolling out Data collection and reporting Strive for continual design, accuracy and relevancy testing of measures and the way data are collected and reported Ensure data collection is not an end in itself but a driver of positive change within the health system, and avoid onerous data collection and reporting overburden Real-time reporting should be the goal, which delivers comparative clinical performance data back to health service providers and organisations Stakeholders Engage key stakeholders, especially clinicians and senior leadership, but also the media and general public Change the culture of provider organisations to foster learning over punishing and judging, which also allows clinical staff to raise questions and concern

Implications of the National Disability Insurance Scheme for health service delivery

Executive summary The National Disability Insurance Scheme (NDIS) is not a health scheme. The NDIS funds disability support and a range of related services designed to maximise the independence of a person with a disability. Health care is a specific exclusion. The NDIS is organisationally separate from both the health system and the aged care sector. At the national level, the NDIS is the responsibility of the Minister for Social Services (and not the Minister for Health) and is being administered by the National Disability Insurance Agency (NDIA), which is an independent statutory agency. While the NDIS is not a health scheme, and health care is a specific exclusion, it will intersect with the health system on a number of levels. To ensure the NDIS does not lead to fragmented care for participants, the Department of Health, the Department of Social Services and the NDIA will need to work closely to monitor and resolve any issues that arise during the implementation phase. This will require active, joint collaboration to develop appropriate policy responses.   Recommendations for action 1. Establish formal Department of Health, Department of Social Service and National Disability Insurance Agency tripartite working group with the following roles and responsibilities: Education and information for key targeted audiences regarding eligibility requirement and other key implications of the NDIS and the National Injury Insurance Scheme (NIIS) Workforce implications monitored and addressed in a coordinated manner Patient inequity issues monitored and coordinated policy responses undertaken Permanent and fluctuating impairment required coordinated care and active policy responses Mental health implications need to be better understood and coordinate actions to be taken to overcome barriers Service prevision boundary disputes between health and disability sectors require a resolution mechanism through negotiation rather than determined solely by the NDIA Timely access issues monitored and a fast track system for hospital referrals to/from the NDIS developed Inconsistency with the 2011 National Health Reform Agreement monitored and addressed as appropriate 2. While it is the responsibility of the Department of Social Services and the NDIA to work toward a nationally consistent approach as the scheme moves to full roll-out, the Department of Health should monitor roll-out to ensure health services are not negatively impacted. 3. Review the NDIS evaluation in order to inform the health system with applicable lessons. At the system level, the NDIS presents opportunities to learn more about individualised service planning and funding, and better ways to measure need and outcomes

Overweight and obesity among Indigenous children: individual and social determinants

Factors influencing obesity are not confined to the health portfolio, argues this paper. Instead the factors occur across portfolios including housing, education, employment, social welfare and community development. Executive summary What is the problem? Obesity rates are higher among Indigenous, compared to non-Indigenous, Australians, and this problem begins in early childhood. If this trend of increasing obesity among Indigenous children continues, there will be a corresponding negative impact on health, and the gap in life expectancy will widen, not close. Childhood is a critical life stage, and early intervention strategies can reap a lifetime of rewards. Childhood obesity prevention programs have predominantly targeted individual behaviours (such as physical inactivity and unhealthy diet) and have been unsuccessful to date. The approach needs to shift to addressing social and economic factors, rather than individual behaviours in isolation. Why is it relevant to policy makers? In February 2014, Prime Minister Tony Abbott acknowledged that progress against the Closing the Gap targets was disappointing and that a change of direction was needed. This should encompass a shift in focus away from individual factors and onto social and economic factors. As an example of relevance to state and territory policy makers, the ACT Chief Minister and Minister for Health Katy Gallagher has called for obesity prevention efforts to move beyond the health portfolio, towards a coordinated effort across all arms of government. This requires action on the food environment, schools, workplaces, urban planning and social inclusion. As part of her plan, Gallagher recently announced a ban on soft drinks in public schools in the ACT. What does the evidence say? To date, there has been a limited evidence base to guide the development of programs and policies for obesity prevention among Indigenous children. It has been recognised that social and economic factors are important, but empirical evidence is required to quantify the relative contribution of these factors and to work out which factors are the most important ones to target first. Data from the Longitudinal Study of Indigenous Children (LSIC), a national study managed by the Australian Government Department of Social Services, show that individual choices are strongly influenced by the broader context. In 2011, Indigenous children experiencing disadvantage at both the individual and the neighbourhood level consumed significantly more soft drink than more advantaged Indigenous children in the survey. Maternal education, housing stability, urbanisation and neighbourhood disadvantage are important factors affecting Indigenous children’s soft drink consumption, and therefore risk of obesity. What should policymakers do? If programs are to change the health behaviours and health outcomes of Indigenous children successfully, they must address social and economic factors — the context in which individual choices are made. Factors influencing obesity are not confined to the health portfolio; policy development should occur across portfolios including housing, education, employment, social welfare and community development. The broader benefits of such programs should be considered when weighing the cost. Research conducted at the National Centre for Social and Economic Modelling, University of Canberra, estimated that if Australia were to adopt the recommendations of the WHO Commission on Social Determinants of Health report "Closing the gap within a generation", half a million Australians could avoid suffering a chronic disease; 170,000 more Australians could enter the workforce (generating earnings of $8 billion); and$4 billion in redundant welfare support payments would be saved. The implications for the wellbeing of Indigenous Australians, and for health equity, have not been calculated, but are undoubtedly considerable

Are our policies and laws leading to treatment delays for people with schizophrenia?

Under Australian mental health laws, people with schizophrenia can only be involuntarily committed to a mental health facility if they are assessed and it is determined that their illness is making them dangerous to themselves or others. To determine whether they are to undergo involuntary treatment, mental health workers must assess people against an ‘Obligatory Dangerousness Criterion’. This criterion is an advance on methods used prior to the mid-1970s, when many countries authorised involuntary commitment to a mental health facility on medical certification alone, without court approval or any proof of an emergency situation. An Obligatory Dangerousness Criterion is now widely used in Australia, the USA, and some areas of Canada and Europe as the means by which patients are assessed for the appropriateness of involuntary (compulsory) treatment. There is no doubt the policy underpinning its use was well intentioned; an Obligatory Dangerousness Criterion was originally developed in an attempt to bett er balance the rights of the mentally ill with the need to protect the public. However, over time some experts have begun to raise questions about the utility of this criterion, suggesting that it sometimes means patients don’t get access to necessary treatment as quickly as they should

Accreditation of health services: is it money and time well spent?

The research evidence shows that accreditation is a useful tool for stimulating improvements in the quality and safety of health services. Accreditation programs are deployed widely to monitor and promote safety and quality in healthcare. Governments, health service organisations and accreditation agencies have invested considerable resources into accreditation programs, but to date evidence of their effectiveness is limited and varied in some areas. Without more robust evidence – on what aspects of accreditation programs work, in what contexts and why – policymakers will have to continue drawing on expert opinion, small-scale program evaluations and cautious comparative assessments of the literature when reviewing, revising or implementing  accreditation programs

Does case management improve outcomes for people with schizophrenia?

The Australian and New Zealand clinical practice guidelines recommend intensive case management for people with first-episode psychosis or an acute relapse of schizophrenia. Often initiated following discharge from hospital or transfer from community-based acute care, case management is a collaborative, community-based program designed to ensure people receive quality health care and integrated support services. Case management may provide substantial benefits for people suffering severe mental illnesses like schizophrenia, however, before case management services are made universally available, more work needs to be done to determine when, and for whom, these services are most effective