Evidence-based health care policy in reimbursement decisions : lessons from a series of six equivocal case-studies

Context: Health care technological evolution through new drugs, implants and other interventions is a key driver of healthcare spending. Policy makers are currently challenged to strengthen the evidence for and cost-effectiveness of reimbursement decisions, while not reducing the capacity for real innovations. This article examines six cases of reimbursement decision making at the national health insurance authority in Belgium, with outcomes that were contested from an evidence-based perspective in scientific or public media. Methods: In depth interviews with key stakeholders based on the adapted framework of Davies allowed us to identify the relative impact of clinical and health economic evidence; experience, expertise & judgment; financial impact & resources; values, ideology & political beliefs; habit & tradition; lobbyists & pressure groups; pragmatics & contingencies; media attention; and adoption from other payers & countries. Findings: Evidence was not the sole criterion on which reimbursement decisions were based. Across six equivocal cases numerous other criteria were perceived to influence reimbursement policy. These included other considerations that stakeholders deemed crucial in this area, such as taking into account the cost to the patient, and managing crisis scenarios. However, negative impacts were also reported, in the form of bypassing regular procedures unnecessarily, dominance of an opinion leader, using information selectively, and influential conflicts of interest. Conclusions: 'Evidence' and 'negotiation' are both essential inputs of reimbursement policy. Yet, purposely selected equivocal cases in Belgium provide a rich source to learn from and to improve the interaction between both. We formulated policy recommendations to reconcile the impact of all factors identified. A more systematic approach to reimburse new care may be one of many instruments to resolve the budgetary crisis in health care in other countries as well, by separating what is truly innovative and value for money from additional 'waste'

Angel Whispers : Reverie Transcription

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How to reform western care payment systems according to physicians, policy makers, healthcare executives and researchers: a discrete choice experiment

Background: Many developed countries are reforming healthcare payment systems in order to limit costs and improve clinical outcomes. Knowledge on how different groups of professional stakeholders trade off the merits and downsides of healthcare payment systems is limited. Methods: Using a discrete choice experiment we asked a sample of physicians, policy makers, healthcare executives and researchers from Canada, Europe, Oceania, and the United States to choose between profiles of hypothetical outcomes on eleven healthcare performance objectives which may arise from a healthcare payment system reform. We used a Bayesian D-optimal design with partial profiles, which enables studying a large number of attributes, i.e. the eleven performance objectives, in the experiment. Results: Our findings suggest that (a) moving from current payment systems to a value-based system is supported by physicians, despite an income trade-off, if effectiveness and long term cost containment improve. (b) Physicians would gain in terms of overall objective fulfillment in Eastern Europe and the US, but not in Canada, Oceania and Western Europe. Finally, (c) such payment reform more closely aligns the overall fulfillment of objectives between stakeholders such as physicians versus healthcare executives. Conclusions: Although the findings should be interpreted with caution due to the potential selection effects of participants, it seems that the value driven nature of newly proposed and/or introduced care payment reforms is more closely aligned with what stakeholders favor in some health systems, but not in others. Future studies, including the use of random samples, should examine the contextual factors that explain such differences in values and buy-in. JEL classification: C90, C99, E61, I11, I18, O5

The general results of the RN4CAST survey in Italy

The issue of health workforce shortage and in particular of nurses, has been debated globally for almost three decades (Aiken & Mullinix 1987, Aiken et al. 1996, 2001, 2010), and has been exacerbated by the recent global financial crisis. The European RN4CAST project has shifted focus from considering only nursing workforce planning and workforce volumes to considering the impact of adequate nurse-patient ratios and work environment on patient safety and the quality of care (Sermeus et al. 2011)

Approximation of fixed points of nonexpansive mappings and quasinonexpansive mappings in a Hilbert space

In this paper, we give a simple proof and some generalizations of results in Falset, Llorens-Fuster, Marino, and Rugiano (2016).Comment: 8 page

Healthcare payment reforms across western countries on three continents: Lessons from stakeholder preferences when asked to rate the supportiveness for fulfilling patients’ needs

International audienceTo test the hypothesis that care typology-being complex and highly unpredictable versus being clear-cut and highly predictable-guides healthcare payment preferences of physicians, policy makers, healthcare executives, and researchers. We collected survey data from 942 stakeholders across Canada, Europe, Oceania, and the United States. A total of 48 international societies invited their members to participate in our study. Study design Cross-sectional analysis of stakeholder survey data linked to four scenarios of care typology: primary prevention, trial-and-error care, standard care and network care. Principal findings We identified two “extremes”: (1) dominant preferences of physicians, who embraced fee for service (FFS), even when this precludes the advantages of other payment systems associated with a minimal risk of harm (OR 1.85 for primary prevention; OR 1.89 for standard care, compared to non-physicians); and (2) the dominant preferences of healthcare executives and researchers, who supported quality bonus or adjustment (OR 1.92) and capitation (OR 2.05), respectively, even when these could cause harm. Conclusions Based on exploratory findings, we can cautiously state that payment reform will prove to be difficult as long as physicians, healthcare executives, and researchers misalign payment systems with the nature of care. Replication studies are needed to (dis)confirm our findings within representative subsamples per area and stakeholder grou

Psychological impact and recovery after involvement in a patient safety incident: A repeated measures analysis

OBJECTIVE: To examine individual, situational and organisational aspects that influence psychological impact and recovery of a patient safety incident on physicians, nurses and midwives. DESIGN: Cross-sectional, retrospective surveys of physicians, midwives and nurses. SETTING: 33 Belgian hospitals. PARTICIPANTS: 913 clinicians (186 physicians, 682 nurses, 45 midwives) involved in a patient safety incident. MAIN OUTCOME MEASURES: The Impact of Event Scale was used to retrospectively measure psychological impact of the safety incident at the time of the event and compare it with psychological impact at the time of the survey. RESULTS: Individual, situational as well as organisational aspects influenced psychological impact and recovery of a patient safety incident. Psychological impact is higher when the degree of harm for the patient is more severe, when healthcare professionals feel responsible for the incident and among female healthcare professionals. Impact of degree of harm differed across clinicians. Psychological impact is lower among more optimistic professionals. Overall, impact decreased significantly over time. This effect was more pronounced for women and for those who feel responsible for the incident. The longer ago the incident took place, the stronger impact had decreased. Also, higher psychological impact is related with the use of a more active coping and planning coping strategy, and is unrelated to support seeking coping strategies. Rendered support and a support culture reduce psychological impact, whereas a blame culture increases psychological impact. No associations were found with job experience and resilience of the health professional, the presence of a second victim support team or guideline and working in a learning culture. CONCLUSIONS: Healthcare organisations should anticipate on providing their staff appropriate and timely support structures that are tailored to the healthcare professional involved in the incident and to the specific situation of the incident

Methodological considerations when translating "burnout"

No study has systematically examined how researchers address cross-cultural adaptation of burnout. We conducted an integrative review to examine how researchers had adapted the instruments to the different contexts. We reviewed the Content Validity Indexing scores for the Maslach Burnout Inventory-Human Services Survey from the 12-country comparative nursing workforce study, RN4CAST. In the integrative review, multiple issues related to translation were found in existing studies. In the cross-cultural instrument analysis, 7 out of 22 items on the instrument received an extremely low kappa score. Investigators may need to employ more rigorous cross-cultural adaptation methods when attempting to measure burnout