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.

[Characteristics and healthcare utilization of patients with highest costs of care]. / Kenmerken en zorggebruik van patiënten met de hoogste zorgkosten.

OBJECTIVE: To determine characteristics and healthcare utilization of high-cost patients in the Netherlands. DESIGN: Cross-sectional study, using claim data for 2013 from one Dutch health insurer. Analyses were limited to the curative health system (care that falls under the Health Insurance Act), including voluntary supplementary insurance. METHOD: We established total healthcare costs per beneficiary by summing all claims with a starting date in 2013. We categorized hospital-related diagnosis related groups (DRGs) and mental health care DRGs according to the ICD-10 International Classification of Diseases main chapters and sub-chapters. Per patient we determined which ICD-10-(sub-)chapter carried the highest costs. In addition, we developed several indicators for healthcare utilization and analysed healthcare utilization using descriptive statistics. Finally, we broke down high-cost patients by age group and compared characteristics and health care utilization between age groups. RESULTS: High-cost patients, those in the top 1% in 2013, incurred an average total cost of over € 56,000 per patient. They were treated by multiple providers for numerous health problems. Approximately one third of high-cost patients had one or more expensive treatments, including transplant surgery, dialysis, expensive drugs, intensive care unit use, or DRGs exceeding € 30,000. The majority of high-cost patients were treated for cardiovascular disorders, neoplasms or mental and behavioural disorders. Though the high-cost patients were relatively old, more than half were younger than 65 years and average costs per patient decreased sharply with age. CONCLUSIONS: There is a need for an integral approach in the treatment of high-cost patients. Tailored policy and interventions are needed to improve care quality and to avoid unnecessarily high costs of care.

[Towards a sustainable, cost-effective mental health care; a policy perspective]. / Op weg naar een duurzame ggz; een beleidsperspectief.

BACKGROUND: After a decade of robust growth in spending, Dutch mental healthcare is on a more stricter budgetary path since 2012. High prevalence of illness and limited spending, imply the need for efficient mental healthcare delivery.
AIM: To advise how mental health care can be managed more efficiently. There will also have to be more differentiation between mild and serious psychiatric illnesses.
METHOD: Review of academic articles and policy studies.
RESULTS: With regard to the treatment of fairly common disorders, more attention needs to be given to integrated basic care and e-health. Employers and stakeholders can perhaps play a role in financing some of these services. Severe mental disorders can be handled more often on an integrated ambulatory basis setting than only in a hospital setting, while scaling down inpatient capacity. These steps would represent a major transition and would require spending cuts and a change in the provider 'landscape'.
CONCLUSION: Sustainable mental healthcare is inseparably linked to an agenda that provides value for money and it implies a major transition. However, in principle, it should be possible to fit these changes into the current system of governance. More attention needs to be given to coordination between the various domains, and to a reduction in administrative costs. Reimbursement methods should align e-health, collaborative care, case-management and best-practice pathways.

Lymphocyte glucocorticoid receptor resistance and depressive symptoms severity: a preliminary report.

OBJECTIVE: Assessment of the temporal interrelationship of neuropsychiatric parameters requires technologies allowing frequent biological measurements. We propose glucocorticoid receptor (GR) function of lymphocytes to assess the temporal relationship between glucocorticoid resistance and the course of major depressive disorder. METHOD: Dexamethasone suppression of lymphocyte proliferation was in vitro assessed via 5-bromo-2' deoxyuridine (BrdU) incorporation in DNA. Optimal conditions were determined using blood of healthy volunteers. Thereafter the relation between depression severity (Hamilton Depression Rating Scale, HDRS, scores), lymphocyte proliferation and morning cortisol levels in blood was studied in thirteen depressed patients, mostly with a history of treatment resistance. RESULTS: Recovery from depression was not directly associated with changes in lymphocyte glucocorticoid resistance. However, a negative correlation was observed between HDRS and BrdU incorporation and a positive correlation between morning cortisol and BrdU incorporation. No significant correlation was found between cortisol and HDRS. Regression analyses showed that HDRS was related to both suppression of BrdU incorporation (beta -0.508, p<0.001) and cortisol levels (beta 0.364, p=0.001) in a highly significant model (F2,60=14,244, p<0.001) Except for one case, such relation could not be found within patients. CONCLUSION: Our preliminary results suggest a mutual relation between lymphocyte GR function, morning cortisol levels and MDD symptom severity. A direct relation between glucocorticoids resistance and recovery may not exist, but glucocorticoid resistance might attenuate or prevent recovery. It is clear that additional studies using larger and more homogenous groups of MDD patients are required to support our findings.

[Infants with a very low birth weight: their development and interaction with their mothers]. / Kinderen met een zeer laag geboortegewicht: hun ontwikkeling en de interactie met hun moeders.

Twenty-eight very low birthweight children (less than or equal to 1500 grams; the VLBW-group) and 24 term born children were studied from birth to 2 years of age. Over this period the interaction of these children with their mothers was observed in 6 naturalistic situations, and other aspects of their development were measured. The VLBW-group consisted of a relatively homogeneous group of healthy preterms, who had no sign of handicap at birth. It emerged that these VLBW-children were more liable to develop various types of problem, although such problems were on the whole not very serious in nature. Interesting differences were observed in mother-infant interaction, particularly in relation to the expression of negative emotions between mother and child. These differences were mainly interpreted in terms of their function in the mutual adaptation of mother and child.

Otitis media with effusion and tubal tonsil (video).

Carbon dioxide laser surgery was performed on children aged 5 to 11 years, on whom either adenoidectomy or tonsilloadenoidectomy had been performed to restore their hearing. We examined 177 ears 18 to 24 months after surgery. Thirty ears (17%) were diagnosed as having otitis media with effusion. Analysis of the endoscopic findings revealed 51% marked tubal tonsil hypertrophy and 33% adenoid tissue hypertrophy. Subjects were operated upon in the dorsal position for a duration of point one second at an amplitude of 15 watts. Six months after surgery, most patients' hearing had returned to almost normal. The tympanograms which were taken 6 months after surgery showed good results in almost every case. Otitis media with effusion was found to have recurred in 3 ears. The effect of adenoidectomy is apparently dependent upon age, the size of adenoids, and the influence of allergies and sinusitis. Furthermore, our cases suggested that tubal tonsil hypertrophy was one of the factors found in recurrent otitis media with effusion in older children. It can thus be inferred that endoscopic examination of the postnasal space is recommended in children with recurrent otitis media with effusion after adenoidectomy, and that carbon dioxide laser surgery is a reliable therapeutic method in the topical treatment of this disease.