InterQuality WP 1 – Incentives and Payment Models. Robert Berenson, M.D. The Urban Institute Warsaw, 18-19 January 2011. Proposal Objectives.
Robert Berenson, M.D.
The Urban Institute
Warsaw, 18-19 January 2011
1 -- Literature and methodology review, definition development
2 -- Input from collaborative partners
3 -- Comparative analysis of incentives and payment models
4 -- Criteria development
From The Health Foundation, London. Authors -- Jon Christianson, U of Minnesota; Sheila Leatherman, U of North Carolina and London School of Economics; and Kim Sutherland, U of Cambridge, 2007 and updated
“Financial incentives… can be described as the influence that payments to organisations and individuals have on the health care services they deliver to consumers… In this review, we focus on explicit financial rewards or sanctions that are directed towards improving the quality of care delivered by organisations or practitioners to patients. However, these rewards or sanctions often are layered on top of or blended with payment approaches designed to affect service delivery in other ways.”
In my view the underlying payment approach provide the stronger incentives that influence provider behavior (organizational and individual) rather than the marginal incentives and should be the primary focus of analysis. (see accompanying paper provided)
I suggest some additional and revised steps and potentially additional useful products.
1 – Create a categorization of the alternative payment methods in the four sectors
2 – Identify attributes (theoretical incentives) of each payment method
3 – Perform required literature review
4 – Identify gaps in the measures used in the lit review to help WP2
5 – Develop the criteria for payment methods, which will mostly be presented as pros and cons
I am not sure at this time whether there are accepted typologies of payment models for each of our sectors. Probably for hospitals and physicians but not sure about outpatient facility and pharmaceuticals, and probably not for integrated care
Also, there is greater need to describe hybrid payment schemes that mixes and matches
Will be an early step based on review of literature syntheses and then review by consortium members for accuracy and completeness
It is useful to develop theoretical delineation of pros and cons of payment methods and then test empirically because there will be large data gaps in literature and yet payment methods need to be adopted and revised continually. Also this analysis should inform the fine-tuning of payment methods, how to guard against provider “misbehavior” and where to emphasize performance metrics. These attributes also involve considerations such as feasibility, potential for “gaming,” etc. and can be informed and modified as evidence comes in.
− internalizes incentives for efficiency within the episode
− potentially aligns incentives across siloed providers
− arguably, is an intermediate step on the way to real integration
− does not fundamentally alter incentive to generate units of service
− be careful about what you wish for, e.g. physician-hospital alignment without determination of appropriateness in a FFS environment
− currently, political challenges in bundling among providers
− technically challenging (esp. for ambulatory care) – vagaries of diagnosis (more episodes in Miami than Minnesota), bias to performance of a procedure in a case rate, sorting out where particular claims are assigned to
Will be performed concurrently with the literature review and updated throughout the project -- and will need to be reviewed by the consortium, as these attributes are based not only on results from literature review but also from expert opinion to address gaps in evidence and to consider practical issues that are outside of impact on quality, costs and equity.
Method of Christianson et al. above
“Electronic searches were performed by the Centre fir Reviews and Dissemination at the University of York, with supplementary searches undertaken by the research team. Electronic searches of MEDLINE, EMBASE, Cochrane, DARE, EconLit. Also, AHRQ, OECD, WHO
Search strategy had 2 parts – 1st, retrieve systematic reviews using a wide range of search terms; 2nd, more limited # of search terms but a wider range of research designs
Define period of study, i.e., Jan 88 – Aug 06 and then extended through June 07.
Then very detailed process of retrieving and reviewing full articles and in every case writing an article summary using a standard abstract format. Reviewed by 2 team members
Majority of articles retrieved through this search process were from the US.
Do we need this kind of thorough primary source review across 4 (really 5) sectors and with need for much greater review of international, not just US, experience?
Can we rely more on secondary sources/ others’ reviews, including OECD, WHO and European Observatory?
Who here can provide advice on conducting formal lit reviews?
WP1 needs to work closely with WP2 because the literature on impact of payment incentives on quality, cost, and equity inherently requires identification of what metrics are used for the assessment.
From literature review, will identify methodological issues with use of various performance metrics and provide that separately to WP2.
We proposed a set of criteria through a consensus process among the consortium members to be used in evaluation current and proposed payment schemes. These included considerations of feasibility, program integrity (i.e. gaming and fraud) as well as the primary end points of quality, cost and equity.
The assumption is that there is no “best” method because specific adoption will vary across health systems based on nature of health system, political culture, strategic considerations, etc.
Accordingly, there needs to be a consensus process across consortium members informed by the work on attributes and literature review, but including considerations of values and balancing objectives (quality, cost, equity, feasibility, etc.)
These might be better laid out as advantages and disadvantages rather than a ranking
Criteria can also be informed by health system experts in our countries and be updated throughout the three year process
Need feedback loop as WPs 3-6 evolve
Categorization of payment schemes in Feb-March – with need for consortium review and comment – by email
Develop first pass at “attributes”, literature review, and identification of measures for use by WP2 Feb – May, with distribution before meeting in Seattle in June
Finalize literature review, June – October
Initiate criteria development process June and probably need a dedicated process for late summer/early fall, ideally in person (first draft due at 8 months – may lapse a little?)