Factors Influencing the Introduction of Value-Based Payment in Integrated Stroke Care: Evidence from a Qualitative Case Study.

Background: To address issues related to suboptimal insight in outcomes, fragmentation, and increasing costs, stakeholders are experimenting with value-based payment (VBP) models, aiming to facilitate high-value integrated care. However, insight in how, why and under what circumstances such models can be successful is limited. Drawing upon realist evaluation principles, this study identifies context factors and associated mechanisms influencing the introduction of VBP in stroke care. Methods: Existing knowledge on context-mechanism relations impacting the introduction of VBP programs (in real-world settings) was summarized from literature. These relations were then tested, refined, and expanded based on a case study comprising interviews with representatives from organizations involved in the introduction of a VBP model for integrated stroke care in Rotterdam, the Netherlands. Results: Facilitating factors were pre-existing trust-based relations, shared dissatisfaction with the status quo, regulatory compatibility and simplicity of the payment contract, gradual introduction of down-side risk for providers, and involvement of a trusted third party for data management. Yet to be addressed barriers included friction between short- and long-term goals within and among organizations, unwillingness to forgo professional and organizational autonomy, discontinuity in resources, and limited access to real-time data for improving care delivery processes. Conclusions: Successful payment and delivery system reform require long-term commitment from all stakeholders stretching beyond the mere introduction of new models. Careful consideration of creating the 'right' contextual circumstances remains crucially important, which includes willingness among all involved providers to bear shared financial and clinical responsibility for the entire care chain, regardless of where care is provided.

Identifying prognostic factors for clinical outcomes and costs in four high-volume surgical treatments using routinely collected hospital data.

Identifying prognostic factors (PFs) is often costly and labor-intensive. Routinely collected hospital data provide opportunities to identify clinically relevant PFs and construct accurate prognostic models without additional data-collection costs. This multicenter (66 hospitals) study reports on associations various patient-level variables have with outcomes and costs. Outcomes were in-hospital mortality, intensive care unit (ICU) admission, length of stay, 30-day readmission, 30-day reintervention and in-hospital costs. Candidate PFs were age, sex, Elixhauser Comorbidity Score, prior hospitalizations, prior days spent in hospital, and socio-economic status. Included patients dealt with either colorectal carcinoma (CRC, n = 10,254), urinary bladder carcinoma (UBC, n = 17,385), acute percutaneous coronary intervention (aPCI, n = 25,818), or total knee arthroplasty (TKA, n = 39,214). Prior hospitalization significantly increased readmission risk in all treatments (OR between 2.15 and 25.50), whereas prior days spent in hospital decreased this risk (OR between 0.55 and 0.95). In CRC patients, women had lower risk of in-hospital mortality (OR 0.64), ICU admittance (OR 0.68) and 30-day reintervention (OR 0.70). Prior hospitalization was the strongest PF for higher costs across all treatments (31-64% costs increase/hospitalization). Prognostic model performance (c-statistic) ranged 0.67-0.92, with Brier scores below 0.08. R-squared ranged from 0.06-0.19 for LoS and 0.19-0.38 for costs. Identified PFs should be considered as building blocks for treatment-specific prognostic models and information for monitoring patients after surgery. Researchers and clinicians might benefit from gaining a better insight into the drivers behind (costs) prognosis.

Design and effects of outcome-based payment models in healthcare: a systematic review.

INTRODUCTION: Outcome-based payment models (OBPMs) might solve the shortcomings of fee-for-service or diagnostic-related group (DRG) models using financial incentives based on outcome indicators of the provided care. This review provides an analysis of the characteristics and effectiveness of OBPMs, to determine which models lead to favourable effects. METHODS: We first developed a definition for OBPMs. Next, we searched four data sources to identify the models: (1) scientific literature databases; (2) websites of relevant governmental and scientific agencies; (3) the reference lists of included articles; (4) experts in the field. We only selected studies that examined the impact of the payment model on quality and/or costs. A narrative evidence synthesis was used to link specific design features to effects on quality of care or healthcare costs. RESULTS: We included 88 articles, describing 12 OBPMs. We identified two groups of models based on differences in design features: narrow OBPMs (financial incentives based on quality indicators) and broad OBPMs (combination of global budgets, risk sharing, and financial incentives based on quality indicators). Most (5 out of 9) of the narrow OBPMs showed positive effects on quality; the others had mixed (2) or negative (2) effects. The effects of narrow OBPMs on healthcare utilization or costs, however, were unfavourable (3) or unknown (6). All broad OBPMs (3) showed positive effects on quality of care, while reducing healthcare cost growth. DISCUSSION: Although strong empirical evidence on the effects of OBPMs on healthcare quality, utilization, and costs is limited, our findings suggest that broad OBPMs may be preferred over narrow OBPMs.

[Do healthcare insurers have too much power?] / Hebben zorgverzekeraars te veel macht?

In the Dutch healthcare system, healthcare insurers act as purchasers of care on behalf of their insured clients. To this end, the insurers form contractual agreements with healthcare providers. In the interest of balanced negotiations regarding price and quality, it is important that neither of the two parties has a disproportionate position of power. This paper discusses whether healthy power relationships exist between healthcare insurers and healthcare providers.

Preconditions for efficiency and affordability in competitive healthcare markets: are they fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland?

CONTEXT: From the mid-1990s several countries have introduced elements of regulated competition in healthcare. The aim of this paper is to identify the most important preconditions for achieving efficiency and affordability under regulated competition in healthcare, and to indicate to what extent these preconditions are fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. These experiences can be worthwhile for other countries (considering) implementing regulated competition (e.g. Australia, Czech Republic, Ireland, Russia, Slovakia, US). METHODS: We identify and discuss ten preconditions derived from the theoretical model of regulated competition and assess the extent to which each of these preconditions is fulfilled in Belgium, Germany, Israel, the Netherlands and Switzerland. FINDINGS: After more than a decade of healthcare reforms in none of these countries all preconditions are completely fulfilled. The following preconditions are least fulfilled: consumer information and transparency, contestable markets, freedom to contract and integrate, and competition regulation. The extent to which the preconditions are fulfilled differs substantially across the five countries. Despite substantial progress in the last years in improving the risk equalization systems, insurers are still confronted with substantial incentives for risk selection, in particular in Israel and Switzerland. Imperfect risk adjustment implies that governments are faced with a complex tradeoff between efficiency, affordability and selection. CONCLUSIONS: Implementing regulated competition in healthcare is complex, given the preconditions that have to be fulfilled. Moreover, since not all preconditions can be fulfilled simultaneously, tradeoffs have to be made with implications for the levels of efficiency and affordability that can be achieved. Therefore the optimal set of preconditions is not only an empirical question but ultimately also a matter of societal preferences.

Some pain, no gain: experiences with the no-claim rebate in the Dutch health care system.

To contain expenditures in an increasingly demand driven health care system, in 2005 a no-claim rebate was introduced in the Dutch health insurance system. Since demand-side cost sharing is a very controversial issue, the no-claim rebate was launched as a consumer friendly bonus system to reward prudent utilization of health services. Internationally, the introduction of a mandatory no-claim rebate in a social health insurance scheme is unprecedented. Consumers were entitled to an annual rebate of 255 eruos if no claims were made. During the year, all health care expenses except for GP visits and maternity care were deducted from the rebate until the rebate became zero. In this article, we discuss the rationale of the no-claim rebate and the available evidence of its effect. Using a questionnaire in a convenience sample, we examined people's knowledge, attitudes, and sensitivity to the incentive scheme. We find that only 4% of respondents stated that they would reduce consumption because of the no-claim rebate. Respondents also indicated that they were willing to accept a high loss of rebate in order to use a medical treatment. However, during the last month of the year many respondents seemed willing to postpone consumption until the next year in order to keep the rebate of the current year intact. A small majority of respondents considered the no-claim rebate to be unfair. Finally, we briefly discuss why in 2008 the no-claim rebate was replaced by a mandatory deductible.

Access to coverage for high-risks in a competitive individual health insurance market: via premium rate restrictions or risk-adjusted premium subsidies?

A competitive market for individual health insurance tends to risk-adjusted premiums. Premium rate restrictions are often considered a tool to increase access to coverage for high-risk individuals in such a market. However, such regulation induces selection which may have several adverse effects. As an alternative approach we consider risk-adjusted premium subsidies. Empirical results of simulated premium models and subsidy formulae are presented. It is shown that sufficiently adjusted subsidies eliminate the need for premium rate restrictions and consequently avoid their adverse effects. Therefore, the subsidy approach is the preferred strategy to increase access to coverage for high-risk individuals.

Towards a reinforced agency role of health insurers in Belgium and The Netherlands.

This article describes some recent developments in health insurance in Belgium and the Netherlands. Both countries are moving towards greater financial responsibility of health insurers by means of risk-adjusted capitation payment systems. Although for the unwary observer it would appear as if both countries were following similar paths towards a common model, the authors make clear that rather different underlying rationales are driving these trends. In the Netherlands, the grand design 'Dekker proposal' for regulated competition has been replaced by a more gradual implementation of reforms with more limited scope. The ultimate goal remains a system of managed competition, albeit only for part of the health care services. In Belgium, prospective risk-adjusted capitation payment has always been at the heart of the original system in principle since its inception, but non-enforcement led to retrospective and inequitable financing in practice. Although the rhetoric of managed competition has never been used explicitly in any Belgian official government policy document, it seems unlikely that putting the insurers at financial risk without simultaneously also reinforcing their agency role by providing instruments for care management-like, for example, selective contracting--is viable in the longer run without jeopardizing the solvency of the insurers. The authors conclude that although the logic of the managed competition model is appealing, the lack of conclusive empirical evidence of success elsewhere makes governments reluctant to surrender their traditional cost containment tools. But making insurers financially accountable without simultaneously providing them with tools to take on the accountability seems useless and illogical.

Priority care for employees: a blessing in disguise?

This paper discusses the efficiency and equity effects of priority care for employees. Recent privatization of workers' compensation insurance in the Netherlands caused an increasing tension between public responsibility for health care cost-containment and private responsibility for sick pay. As a result of strict supply side regulation, waiting lists increased, while at the same time employers became fully responsible for sick pay. To reduce sick pay and production losses, employers are prepared to pay for priority care by using available excess capacity. We argue that the criteria of Pareto and Rawls can provide a rationale for the resulting differential treatment of employees and non-employees. However, such a justification crucially depends on weights society assigns to absolute versus relative improvements in access to health care.

Health care reform in The Netherlands: balancing corporatism, etatism, and market mechanisms.

The transformation of the Dutch health care system and the impetus behind the market-oriented health care reforms implemented since 1989 are examined. During the postwar period, the gradual transformation of the Dutch health care system was interrupted twice by attempts to introduce radical reforms: the 1974 comprehensive health plan and the 1987 pro-competitive national health insurance program. The market-oriented reform involves a fundamental change of the incentive structure for insurers and providers. The objective is to interest both parties in containing costs and improving efficiency while preserving universal access through central redistributive financing. In the Dutch political context, radical reform proposals can be introduced only by a prolonged series of incremental changes, which offer the corporatist organizations of providers and insurers ample opportunity to dismantle the original reform design. The 1974 comprehensive health plan failed largely because of this corporatist trap. The 1987 market-oriented reform program faced the same risks, although it appeared to offer an ingenious political compromise. Private health insurers were particularly successful in slowing the reform by frustrating the development of a prospective, risk-adjusted payment mechanism. The resistance of corporatist organizations to the 1974 and 1987 reforms provoked a largely unplanned process of creeping etatization. Paradoxically, the present market-oriented reforms coincide with far-reaching state interventions in determining provider fees. A new, more satisfactory balance between corporatism, etatism, and market mechanisms must still be found.

Should catastrophic risks be included in a regulated competitive health insurance market?

In 1988 the Dutch government launched a proposal for a national health insurance based on regulated competition. The mandatory benefits package should be offered by competing insurers and should cover both non-catastrophic risks (like hospital care, physician services and drugs) and catastrophic risks (like several forms of expensive long-term care). However, there are two arguments to exclude some of the catastrophic risks from the competitive insurance market, at least during the implementation process of the reforms. Firstly, the prospects for a workable system of risk-adjusted payments to the insurers that should take away the incentives for cream skimming are, at least during the next 5 years, more favorable for the non-catastrophic risks than for the catastrophic risks. Secondly, even if a workable system of risk-adjusted payments can be developed, the problem of quality skimping may be relevant for some of the catastrophic risks, but not for non-catastrophic risks. By 'quality skimping' we mean the reduction of the quality of care to a level which is below the minimum level that is acceptable to society. After 5 years of health care reforms in the Netherlands new insights have resulted in a growing support to confine the implementation of the reforms to the non-catastrophic risks. In drawing (and redrawing) the exact boundaries between different regulatory regimes for catastrophic and non-catastrophic risks, the expected benefits of a cost-effective substitution of care have to be weighted against the potential harm caused by cream skimming and quality skimping.

Workable competition in health care: prospects for the Dutch design.

Since 1989 a gradual restructuring of the Dutch health care system is taking place to realize a multiple choice social health insurance system with workable competition among insurers and among health care providers. This paper investigates whether the structural change will induce the intended competition. An examination of the characteristics of the market for health insurance, physician services and hospital services in the Netherlands points out that the scope for competition is limited. If competition is to work, rather extensive government regulation to monitor the conduct of both providers and insurers is needed. Without an effective antitrust policy a high degree of concentration and collusion is likely.

Antitrust policy in the Dutch health care system and the relevance of EEC competition policy and U.S. antitrust practice.

Dutch health care policy is undergoing a radical shift from a planning-oriented towards a market-oriented approach. A fundamental restructuring of the health care financing system should bring about workable competition among providers and among health insurers. As the result of both government regulation and anticompetitive self-regulation strong cartels and dominant positions are deeply rooted in the present Dutch health care system. In order to be successful structural reforms should be supported by an effective antitrust policy. However, present Dutch antitrust policy is too lenient to fulfil this necessary condition. EEC competition policy is far more stringent, but for several reasons its relevance will be limited. For an effective enforcement of national antitrust policy in health care, the so far unique American experience in this field provides some useful lessons.

Escaping from the dual organization: physician self-governance.

This article discusses a way of coping, in a time of limited resources, with the dual organization problem in hospitals. First, the historical roots of the dual organization problem are analysed. It is ascertained that the power structure within the hospital crucially depends on the socioeconomic circumstances and the state of medical knowledge. Since the health care systems of most industrialized countries are in transition from a stage of rapid expansion into a stage of consolidation, new problems arise which cannot be adequately handled within the context of the dual organization structure. The crux of the dual organization problem lies in the separation of the related responsibilities for resource allocation and patient care. Most proposals to solve this problem try to develop models of shared authority, which may be elegant in theory but often raise tremendous problems when implemented in practice. A straightforward solution would be the reunion of both responsibilities under one head, the physician-executive. It is argued that in a situation of limited funds for medical care, patients, physicians as well as administrators will be best off when physicians become primarily responsible for the resource allocation within the hospital. Some empirical evidence for this supposition is discussed. Finally, attention is paid to the prerequisites for, and implementation of, physician self-governance.