First Do No Harm: An Opinion on Bundled Care for Stroke Patients.

The Center for Medicare and Medicaid Innovation under the Centers for Medicare and Medicaid Services has invited institutions to demonstrate ways to bundle services into a 90-day episode of acute care that will lower costs and hospital re-admission rates. While these goals are laudable, they overlook the need for and value attained in postacute treatment. This article argues for elimination of the diagnosis of stroke from the proposed demonstration project due to misaligned financial incentives that will severely compromise patient outcomes.

Medical ethics: enhanced or undermined by modes of payment?

BACKGROUND: In the medical literature [1, 2, 7], the view prevails that any change away from fee-for-service (FFS) jeopardizes medical ethics, defined as motivational preference in this article. The objective of this contribution is to test this hypothesis by first developing two theoretical models of behavior, building on the pioneering works of Ellis and McGuire [4] and Pauly and Redisch [11]. Medical ethics is reflected by a parameter α, which indicates how much importance the physician attributes to patient well-being relative to his or her own income. Accordingly, a weakening of ethical orientation amounts to a fall in the value of α. While traditional economic theory takes preferences as predetermined, more recent contributions view them as endogenous (see, e.g., Frey and Oberholzer-Gee [5]). METHODS: The model variant based on Ellis and McGuire [4] depicts the behavior of a physician in private practice, while the one based on Pauly and Redisch [11] applies to providers who share resources such as in hospital or group practice. Two changes in the mode of payment are analyzed, one from FFS to prospective payment (PP), the other to pay-for-performance (P4P). One set of predictions relates physician effort to a change in the mode of payment; another, physician effort to a change in α, the parameter reflecting ethics. Using these two relationships, a change in ethics can observationally be related to a change in the mode of payment. The predictions derived from the models are pitted against several case studies from diverse countries. RESULTS: A shift from FFS to PP is predicted to give rise to a negative observed relationship between the medical ethics of physicians in private practice under a wide variety of circumstances, more so than a shift to P4P, which can even be seen as enhancing medical ethics, provided physician effort has a sufficiently high marginal effectiveness in terms of patient well-being. This prediction is confirmed to a considerable degree by circumstantial evidence coming from the case studies. As to physicians working in hospital or group practice, the prediction is again that a transition in hospital payment from FFS to PP weakens their ethical orientation. However, this prediction could not be tested because the one hospital study found relates to a transition to P4P, suggesting that this mode of payment may actually enhance medical ethics of healthcare providers working in a hospital or group practice. CONCLUSION: The claim that moving away from FFS undermines medical ethics is far too sweeping. It can only in part be justified by observed relationships, which even may suggest that a transition to P4P strengthens medical ethics.

Fee Splitting among General Practitioners: A Cross-Sectional Study in Iran.

BACKGROUND: Fee splitting is a process whereby a physician refers a patient to another physician or a healthcare facility and receives a portion of the charge in return. This survey was conducted to study general practitioners' (GPs) attitudes toward fee splitting as well as the prevalence, causes, and consequences of this process. METHODS: This is a cross-sectional study on 223 general practitioners in 2013. Concerning the causes and consequences of fee splitting, an unpublished qualitative study was conducted by interviewing a number of GPs and specialists and the questionnaire options were the results of the information obtained from this study. RESULTS: Of the total 320 GPs, 247 returned the questionnaires. The response rate was 77.18%. Of the 247 returned questionnaires, 223 fulfilled the inclusion criteria. Among the participants, 69.1% considered fee splitting completely wrong and 23.2% (frequently or rarely) practiced fee splitting. The present study showed that the prevalence of fee splitting among physicians who had positive attitudes toward fee splitting was 4.63 times higher than those who had negative attitudes. In addition, this study showed that, compared to private hospitals, fee splitting is less practiced in public hospitals. The major cause of fee splitting was found to be unrealistic/unfair tariffs and the main consequence of fee splitting was thought to be an increase in the number of unnecessary patient referrals. DISCUSSION: Fee splitting is an unethical act, contradicts the goals of the medical profession, and undermines patient's best interest. In Iran, there is no code of ethics on fee splitting, but in this study, it was found that the majority of GPs considered it unethical. However, among those who had negative attitudes toward fee splitting, there were physicians who did practice fee splitting. The results of the study showed that physicians who had a positive attitude toward fee splitting practiced it more than others. Therefore, if physicians consider fee splitting unethical, its rate will certainly decrease. The study claims that to decrease such practice, the healthcare system has to revise the tariffs.

The use of non-economic criteria in pricing and reimbursement decisions in Central and Eastern Europe: issues, trends and recommendations.

INTRODUCTION: According to some experts, there is still room for improvement with regard to the inclusion of ethical considerations in Health Technology Assessment (HTA). AREAS COVERED: The pros and cons of the introduction of non-economic criteria in the HTA process in Central and Eastern Europe (CEE) are discussed. In comparison to Western Europe, financial considerations are even more important in CEE settings; however, it could also be said that attachment to equity and justice is part of CEE's heritage. Therefore, the trade-off between conflicting principles is evaluated. Expert commentary: To ensure the right balance between equity and efficiency in decision making, the current HTA framework has to be further augmented to allow all conflicting criteria to be addressed to a satisfactory degree. Following other examples, the applicability of multi criteria decision analysis technique to CEE settings should be further investigated.

Challenges with participant reimbursement: experiences from a post-trial access study.

Reimbursement of trial participants remains a frequently debated issue, with specific guidance lacking. Trials combining post-trial access and implementation science may necessitate new strategies and models. CAPRISA 008, a post-trial access study testing the feasibility of using family planning services to rollout a prelicensure HIV prevention intervention, tried to balance the real-life scenario of no reimbursement for attendance at public sector clinics with that of a trial including some visits that focused on research procedures and others that focused on standard of care procedures. A reduced reimbursement was offered for 'standard of care' visits, meant primarily to cover transport costs to and from the clinic only. This impacted negatively on accrual, retention and participant morale, primarily due to the protracted delay in regulatory approval, during which time, the costs of living, including travel costs had increased. Relevant guidelines were reviewed and institutional policy was updated to incorporate the South African National Health Research Ethics Committee guidelines on reimbursement (taking into account participant time, travel and inconvenience). The reimbursement amount for 'standard of care' visits was increased accordingly. The question remains whether a trial that combines post-trial access with implementation science, with clear benefits for the participants and the provision of above standard medical care, should have reimbursement rates that approach those of a proof-of-concept trial, for 'standard of care' visits.

Benefits in cash or in kind? A community consultation on types of benefits in health research on the Kenyan Coast.

BACKGROUND: Providing benefits and payments to participants in health research, either in cash or in kind, is a common but ethically controversial practice. While much literature has concentrated on appropriate levels of benefits or payments, this paper focuses on less well explored ethical issues around the nature of study benefits, drawing on views of community members living close to an international health research centre in Kenya. METHODS: The consultation, including 90 residents purposively chosen to reflect diversity, used a two-stage deliberative process. Five half-day workshops were each followed by between two and four small group discussions, within a two week period (total 16 groups). During workshops and small groups, facilitators used participatory methods to share information, and promote reflection and debate on ethical issues around types of benefits, including cash, goods, medical and community benefits. Data from workshop and field notes, and voice recordings of small group discussions, were managed using Nvivo 10 and analysed using a Framework Analysis approach. FINDINGS AND CONCLUSIONS: The methods generated in-depth discussion with high levels of engagement. Particularly for the most-poor, under-compensation of time in research carries risks of serious harm. Cash payments may best support compensation of costs experienced; while highly valued, goods and medical benefits may be more appropriate as an 'appreciation' or incentive for participation. Community benefits were seen as important in supporting but not replacing individual-level benefits, and in building trust in researcher-community relations. Cash payments were seen to have higher risks of undue inducement, commercialising relationships and generating family conflicts than other benefits, particularly where payments are high. Researchers should consider and account for burdens families may experience when children are involved in research. Careful context-specific research planning and skilled and consistent communication about study benefits and payments are important, including in mitigating potential negative effects.

[The new financial compensation system PEPP: an ethical analysis]. / Das neue pauschalierende Entgeltsystem PEPP : Eine ethische Analyse.

BACKGROUND: The new compensation system for psychiatric and psychosomatic institutions (German acronym: PEPP) not only constitutes a change in billing practices, but also necessitates an ethical investigation and analysis of possible consequences of the new legislation for those affected in practice. MATERIAL AND METHODS: Following the presentation of the new PEPP and its consequences for psychiatric practice, problems and areas of conflict will be analyzed from an ethical perspective and discussed. RESULTS: Ethical conflicts exist in the following areas: (1) in the attempt to standardize inpatient care and invoicing for mental illnesses, (2) in poorer treatment for severely ill patients in view of degressive per diem rates, (3) in false incentives due to threshold values e.g. for 1:1 health professional-patient ratios in the case of coercive measures and (4) due to the inappropriate use of a supposed normative neutral quantitative economic model for a qualitative work area that often takes place in human border zones such as complex inpatient care of severely mentally ill patients. CONCLUSION: The ethical analysis of PEPP reveals that apart from the limited opportunities to improve efficiency, there is a considerable ethical risk of loss of quality in psychiatric inpatient care in particular for severely and chronically mentally ill patients.

Payment mechanism and GP self-selection: capitation versus fee for service.

This paper analyzes the consequences of allowing gatekeeping general practitioners (GPs) to select their payment mechanism. We model GPs' behavior under the most common payment schemes (capitation and fee for service) and when GPs can select one among them. Our analysis considers GP heterogeneity in terms of both ability and concern for their patients' health. We show that when the costs of wasteful referrals to costly specialized care are relatively high, fee for service payments are optimal to maximize the expected patients' health net of treatment costs. Conversely, when the losses associated with failed referrals of severely ill patients are relatively high, we show that either GPs' self-selection of a payment form or capitation is optimal. Last, we extend our analysis to endogenous effort and to competition among GPs. In both cases, we show that self-selection is never optimal.

Systematically evaluating the impact of diagnosis-related groups (DRGs) on health care delivery: a matrix of ethical implications.

Swiss hospitals were required to implement a prospective payment system for reimbursement using a diagnosis-related groups (DRGs) classification system by the beginning of 2012. Reforms to a health care system should be assessed for their impact, including their impact on ethically relevant factors. Over a number of years and in a number of countries, questions have been raised in the literature about the ethical implications of the implementation of DRGs. However, despite this, researchers have not attempted to identify the major ethical issues associated with DRGs systematically. To address this gap in the literature, we have developed a matrix for identifying the ethical implications of the implementation of DRGs. It was developed using a literature review, and empirical studies on DRGs, as well as a review and analysis of existing ethics frameworks. The matrix consists of the ethically relevant parameters of health care systems on which DRGs are likely to have an impact; the ethical values underlying these parameters; and examples of specific research questions associated with DRGs to illustrate how the matrix can be applied. While the matrix has been developed in light of the Swiss health care reform, it could be used as a basis for identifying the ethical implications of DRG-based systems worldwide and for highlighting the ethical implications of other kinds of provider payment systems (PPS).

Pitfalls in reimbursement decisions for oncology drugs in South Korea: need for addressing the ethical dimensions in technology assessment.

This study aimed to discover to what extent ethical issues are considered in the reimbursement decision process based on health technology assessment (HTA) in Korea, especially for oncology medications. Public summary documents (PSDs) published by the Health Insurance Review and Assessment Service (HIRA) were analyzed for empirical and normative factors. For external comparison, PSDs presented by corresponding institutions of Australia and the United Kingdom were employed. Furthermore, the opinions of eight expert oncologists were obtained regarding the accountability of the evidence in PSDs. Among 7 oncology drugs, there were differences in the final decisions and empirical factors considered, such as selected comparators and interpretation of evidence between the PSDs from the three institutions. From an ethical viewpoint, the following matters were deficient in the HTA decision-making process for oncology drugs: clear and reasonable standards; identifying and evaluating ethical values; and public accountability for reasonableness about decisions and due process.