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PubMed1993

Fee-for-benefit: a strategy to improve the quality of health care and control costs through reimbursement incentives.

OBJECTIVES: The purpose of this study was to determine whether reimbursement in direct proportion to expected therapeutic benefit is capable of improving the utilization and cost of health care. BACKGROUND: The benefit associated with a particular medical or surgical treatment varies widely from patient to patient. Nevertheless, payment to the provider of the treatment is essentially invariant under the current fee-for-service system. Under an alternative fee-for-benefit strategy, empiric data are used to construct a multivariate model to predict the expected benefit to an individual patient from a particular health care service on the basis of conventional clinical descriptors. The payers and the providers of the service then openly negotiate an explicit economic relation between expected benefit and monetary payment such that payment is directly proportional to benefit. METHODS: Computer simulations were performed to determine the potential impact of this fee-for-benefit strategy with respect to medical versus surgical treatment of coronary artery disease. RESULTS: Compared with conventional fee-for-service, fee-for-benefit resulted in a 12% improvement in patient benefit (quality-adjusted survival), a 22% reduction in provider payments and a 55% increase in cost/benefit (the ratio of benefit to payment). CONCLUSIONS: The incentives embodied in a fee-for-benefit strategy can be an effective mechanism for encouraging more appropriate health care utilization while simultaneously controlling health care costs.

Actuarial Analysis↗
PubMed2004

Delivering generics without regulatory incentives? Empirical evidence from French general practitioners about willingness to prescribe international non-proprietary names.

France presents a unique situation in which the take-off of a generic drug market depends, out of regulatory incentives, on whether physicians choose a prescription method (international non-proprietary names, INN) that can lead to the delivery of these drugs and on whether patients accept them. This paper is aimed at pointing out factors explaining general practitioners' (GPs') willingness to prescribe in INN through data collected from a South-Eastern France representative sample of 600 GPs in March 2002. The main results shed light on the key-role played by GPs' information about drugs and the source which they take it from, by GPs' volume of services and caseloads, and slightly by socio-economic characteristics of patients.

Adult↗
PubMed2006

Incentive-compatible guaranteed renewable health insurance premiums.

Theoretical models of guaranteed renewable insurance display front-loaded premium schedules. Such schedules both cover lifetime total claims of low-risk and high-risk individuals and provide an incentive for those who remain low-risk to continue to purchase the policy. Questions have been raised of whether actual individual insurance markets in the US approximate the behavior predicted by these models, both because young consumers may not be able to "afford" front-loading and because insurers may behave strategically in ways that erode the value of protection against risk reclassification. In this paper, the optimal competitive age-based premium schedule for a benchmark guaranteed renewable health insurance policy is estimated using medical expenditure data. Several factors are shown to reduce the amount of front-loading necessary. Indeed, the resulting optimal premium path increases with age. Actual premium paths exhibited by purchasers of individual insurance are close to the optimal renewable schedule we estimate. Finally, consumer utility associated with the feature is examined.

Adolescent↗
PubMed1989

Pay for performance. Implementing a financial incentive for excellent work.

Based upon my own experience with the system, both staff and supervisors believe that the advantage of pay for performance outweigh the disadvantages. I frequently encountered issues such as how to get a higher rating, what is the incentive to identify a difficult objective if one can pick an easier objective and still receive a higher rating, and where do individuals fall in the ratings compared to peers. In response to achieving a higher rating, the supervisors reviewed the rating system and developed objectives that would receive higher ratings. The supervisors and administrators put emphasis on improved performance, rather than on points. To convince employees to choose more difficult objectives, we explained that objectives should reflect the skills and goals of each employee. The objective serves as an indicator of how well the employee achieved a goal. In dealing with the ranking problem, we told the staff where they ranked in relation to others (eg, top, middle, bottom), but emphasized that the evaluation is confidential and that the results are not to be shared. In conclusion, pay for performance offers a supervisor a detailed objective format for reviewing an employee's performance. For the employees, it provides a means in which their performance review is based on individual achievement of self-selected objectives. Employees are measured against their own standards rather than being compared with others performing the same job.

Clinical Competence↗
PubMed2004

Payer incentives and physical rehabilitation therapy for nonelderly institutional long-term care residents: evidence from Michigan and Ontario.

OBJECTIVE: To examine the effect of payment incentives on the provision of rehabilitation therapy to non elderly nursing home residents. DESIGN: Retrospective cross-sectional study. SETTING: Nursing homes in Michigan or complex continuing care facilities in Ontario, Canada, in 1998 or 1999. PARTICIPANTS: Non elderly nursing home residents (N=5189) admitted to nursing homes. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: The effect of payment on access to physical therapy (PT) and occupational therapy (OT) and total weekly time for each therapy type. RESULTS: A Medicare policy change from cost-based to a patient-specific case-mix payment method was associated with greater likelihood of receiving OT but reduced weekly minutes of PT and OT provided to residents. Medicare cost-based and private insurance were associated with greater likelihood of receiving OT and PT and more therapy time for both types of therapy compared with private-pay residents. Global budget payment was associated with greater access to PT but fewer weekly minutes of OT and PT. CONCLUSIONS: Little information exists to describe the characteristics and treatment of non elderly nursing home residents. This study found that many of these residents received rehabilitation and that residents whose care was paid for by more generous payers, such as Medicare, received more therapy than those paid for by less generous payers.

Activities of Daily Living↗
PubMed2000

Physician-hospital partnerships: incentive alignment through shared governance within a performance improvement structure.

BACKGROUND: Producing accessible, appropriate, and accountable medical care that improves the health of the populations served requires collaborative physician-organization relationships within which performance measurement across the continuum of care occurs. Governance and shared responsibility for performance improvement (PI) through organizational structure and process have proven to be particularly complex challenges. REDESIGN OF THE PI SYSTEM: The Health Alliance of Central New York, based in Syracuse, New York, which consists in part of Crouse Hospital; ambulatory medical care sites and physicians; a physician organization, a physician-hospital organization, and an independent practice association; in February 1997 established a plan for a redesign of the PI system. IMPLEMENTING THE MODEL: In April 1998 the development of joint performance indicators, the Family of Measures, was undertaken. Recommendations for improvements necessary to correct process failures are referred to the medical staff executive committee and/or the appropriate coordinating committee, which then charges the appropriate service-line PI Council(s) with the responsibility for making those improvements. DISCUSSION: Systemwide PI with collaborative decision making by process stakeholders has been a major cultural transition requiring a degree of organizational readiness. Support of the most senior levels of management is critical. Institutional silos do not support shared, participatory decision making and cannot be overcome without strong support from senior management and in many cases the direct support and involvement of the CEO. Integrating information systems represents a considerable challenge: to find hardware and software that will interface properly to produce desired results, to successfully interface computer support personnel into the PI process, and to ensure the commitment to the financial resources to meet the information system requirements. In addition, meaningful and material reengineering requires substantial physician input. Simply reducing length of stay or cost per case is not an outcome that is by and large a strong motivator for physicians. Projects must have meaning at the level of the individual physician to raise interest and create buy-in. Enduring success will be achieved only through achievement of material and salient improvements (for both physicians and the institution) in combination with careful alignment of physician and institutional incentives.

Cooperative Behavior↗
PubMed2005

An investigation of Caesarean sections in three Greek hospitals: the impact of financial incentives and convenience.

BACKGROUND: Caesarean section (CS) rates have been increasing dramatically in the past decades around the world. The objective of our study was to investigate the factors increasing the likelihood of undergoing CS in two public hospitals and one private hospital in Athens, Greece. Specifically, the purpose was primarily to assess the impact of non-medical factors such as private health insurance, potential for making informal payments, physician convenience and socio-economic status on the rate of CS deliveries. METHODS: All available demographic, socio-economic and medical information from the medical records of all deliveries in the three hospitals in January 2002 were analysed. The relative importance of the variables in predicting delivery with CS rather than normal vaginal delivery was calculated in multiple logistic regression models to generate odds ratios (OR). RESULTS: The CS rate in the public hospitals was 41.6% (52.5% for Greeks and 26% for immigrants), while the CS rate in the private hospital was 53% (65.2% for women with private insurance and 23.9% for women who paid directly). In the public hospitals, after controlling for demographic and medical factors, Greek ethnic background, delivery between 8 a.m. and 4 p.m., between 4 p.m. and midnight, and on Monday, Wednesday and Friday were found to increase the likelihood of CS delivery. In the private hospital, having private health insurance is the strongest predictor of CS delivery, followed by delivery between 8 a.m. and 4 p.m., between 4 p.m. and midnight, delivery on a Saturday and being a housewife. CONCLUSION: The results of this study lend support to the hypothesis that physicians are motivated to perform CS for financial and convenience incentives. The recent commercialization of gynaecology services in Greece is discussed, along with its implications on physicians' decisions to perform CS.

Adolescent↗
PubMed1997

Understanding and coping with the new HCFA physician incentives stop-loss insurance rules.

The imposition of physician incentive regulations by the Health Care Financing Administration for Medicare risk and Medicaid managed care contracts has created disclosure and stop-loss reinsurance issues for both physician groups and their contracting health maintenance organizations. This article summarizes the key points of the stop-loss requirements of the new rules, describes the current types of stop-loss reinsurance purchased prior to the effective date of the regulations, and the practical problems of conforming current physician group contracting practices to these rules. The article also provides several suggested steps that physician groups should take to manage the changes required.

Actuarial Analysis↗
PubMed1978

An incentive program designed to develop and reward clinical competence.

A conceptual model is presented for establishing a salary and classification plan which structures a separate career pathway for staff nurses and provides an economic incentive for incrementally achieving higher excellence as a staff practitioner. The plan establishes standard or behavioral norms for four discrete practice levels and systematically measures the content of both line and staff positions to determine their relative difficulty. Consequently equitable salary relationships are made available for all nursing activity, while simultaneously assuring a congruent and competitive posture in the health care community.

Clinical Competence↗
PubMed2001

Incentives and clinical governance: money following quality?

This paper attempts to define quality (particularly in terms of evidence-based health care) and considers the incentives available to bring about improvements in quality. It examines the contribution that economics, as a discipline, can make to the debate on clinical governance. It considers the nature and importance of clinical governance, measuring quality, objectives and behaviour in questions raised concerning objectives and individual and team behaviour.

Evidence-Based Medicine↗
PubMed1998

The impact of financial incentives on quality of health care.

Purchasers of health care could offer financial incentives to plans or providers in order to increase quality. Unfortunately, the current health care market, in which quality is rarely measured and there is no risk adjustment, actively discourages both plans and providers from maximizing quality, resulting in a poor overall level of quality, both in fee-for-service arrangements and health maintenance organizations. Health plans and providers will not focus on quality until mechanisms to correct for risk differences among enrollees can be developed. Although such risk adjustment will be the most important stimulus for quality, it should also be linked to improvements in information systems and agreement on a minimum benefits package, quality reporting standards, and financial solvency requirements.

Delivery of Health Care↗
PubMed1988

Nursing homes as acute care providers. A pilot study of incentives to reduce hospitalizations.

This program was designed to encourage treatment of episodes of acute illness in skilled nursing facilities in order to avoid costly and potentially traumatic admission to hospital. It is part of the Monroe County Long Term Care Program, Inc, system of case management and Medicare and Medicaid waivers, and consists of financial incentives, paid by Medicare, to facilities and to responsible physicians to evaluate and care for acutely ill patients in the SNF's when medically safe and feasible. A retrospective evaluation using a physician assessment committee concluded that among the first 112 patients in the program, 76% were very probably saved hospitalization or at least an emergency room visit. Acute bacterial infection was the most common category of episode, occurring in 46% of cases. Considerable savings to both Medicare and Medicaid were estimated to have resulted.

Acute Disease↗
PubMed1994

Safety belt education using visual crash images and low-cost incentives.

Automobile safety belt use among teen-agers remains low despite high crash morbidity and mortality. This article describes a model of a community-based safety belt promotional program. Ten public high schools, with student club and administrative support, were selected from across Mississippi. Safety belt assemblies, which created vivid crash images, were conducted using police officers, ambulance personnel, people with paraplegia, football players, and others. Low-cost incentives were awarded to buckled students over a 10-week period. Implementation of the program resulted in a mean increase of 21% in male safety belt use and 17% in female safety belt use. Concepts used in the program are reproducible, at minimal cost, by using personnel found in most communities.

Adolescent↗
PubMed2004

An analysis of Medicare's Incentive Payment program for physicians in health professional shortage areas.

CONTEXT: Medicare's Incentive Payment (MIP) program provides a 10% bonus payment to providers who treat Medicare patients in rural and urban areas where there is a shortage of generalist physicians. PURPOSE: To examine the experience of Alaska, Idaho, North Carolina, South Carolina, and Washington with the MIP program. We determined the program's utilization and which types of physicians received payments. METHODS: Retrospective cohort design, utilizing complete 1998 Medicare Part B data. Physician specialty was determined through American Medical Association data. Rural status was determined by linking the physician business ZIP code to its Rural-Urban Commuting Area code (RUCA). FINDINGS: There were 2,220,275 patients and 39,749 providers in the cohort, including 9,769 (24.6%) generalists, 21,331 (53.7%) specialists, and 8,649 (21.8%) nonphysician providers. Over $4 million in bonus payments (median payment = $173) were made to providers in HPSAs. Specialists and urban providers received 58% and 14% of the bonus reimbursements, respectively. Two million dollars in payments were not distributed because the providers did not claim them. Over $2.8 million in bonus claims were distributed to providers who likely did not work in approved HPSA sites. CONCLUSIONS: The MIP bonus payments given to providers are small. Many providers who should have claimed the bonus did not, and many providers who likely did not qualify for the bonus claimed and received it. Consideration should be given to focusing and enlarging the bonus payments to specific providers, rather than rewarding all providers equally. Policy makers should also consider a system that prospectively determines provider eligibility.

Alaska↗
PubMed1987

Financial incentives of subregional RAWP.

Accounting for the cross boundary flows of residents from one health authority treated by another has been considered by the review of the Resource Allocation Working Party (RAWP) formula by the National Health Service Management Board. A common concern is that the approximate costs used are unfair to those authorities (typically those with teaching hospitals) that are likely to treat more complex cases. This paper argues that when spending exceeds the target allowance for acute services this is more likely to be due to district residents using services at a high rate than to inadequate compensation for inflows. Districts where residents make a high use of services are often those where there are large flows across district boundaries. Since authorities cannot control outflows there is little they can do to reduce their residents' high use of services. Furthermore, curious financial incentives can be inferred for clinicians in these districts if they were to take effective action to bring their district's spending to target levels. These problems are discussed to illuminate problems of accounting for cross boundary flows that alternatives to current practice must resolve.

Health Resources↗
PubMed2006

Effect of the UK incentive-based contract on the management of patients with stroke in primary care.

BACKGROUND AND PURPOSE: We wished to ascertain whether a new contract based on financial incentives for general practitioners has been associated with improved recording of quality indicators for patients with stroke and whether there was evidence of any difference in change between sex, age, and deprivation groups. METHODS: In a serial cross-sectional study, patients from 310 general practices with a computer record of transient ischemic attack or stroke in Scotland were analyzed for their recording of quality indicators before and after the introduction of a new quality-based contract on March 31, 2004. Multivariate analyses were used to explore any differences in recording between age, sex, and deprivation groups. RESULTS: Documentation of quality indicators increased over time, with absolute increases for individual indicators ranging from 32.3% to 52.1%. There was a large increase in the documentation of quality indicators among the oldest patients (>75 years) and the most affluent patients. This tended to attenuate age groups differences and to exacerbate differences between deprivation groups. Women tended to have larger increases in documentation than men; however, sex differences persisted, with women less likely than men to have smoking habits recorded (adjusted odds ratio, 0.87; 95% confidence interval, 0.81 to 0.95) or to receive antiplatelet or anticoagulant therapy (adjusted odds ratio, 0.93; 95% confidence interval, 0.86 to 0.99). CONCLUSIONS: The recording and management of quality indicators among patients with stroke increased substantially. However, inequitable care exists, which may have important implications for female, older, and more deprived subgroups in terms of stroke recurrence and mortality.

Age Distribution↗
PubMed1995

Incentive effects of workers' compensation benefits: a literature synthesis.

Increasingly, the health care community and public policymakers are recognizing the role of economic and psychosocial factors in disability in addition to their traditional attention to environmental, physical, and somatic influences on health and illness. In particular, current discussions of health reform include serious consideration of the integration of workers' compensation and health plan benefits. This article synthesizes what is known regarding one important aspect of health policy: the effects on disability behavior of changes in workers' compensation benefits. The best available literature reveals that an increase of 10 percent in workers' compensation benefits is related to a 1 to 11 percent increase in the frequency of workers' compensation claims and a 2 to 11 percent increase in duration per claim. The article examines the sensitivity of these parameter estimates to differences in research design and proposes an idealized study methodology that, the authors hope, would improve the precision of estimates of the incentive effects of workers' compensation payments.

Accidents, Occupational↗