Abstract
Background: In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population. This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Methods: We applied a systematic approach to assess the impact of the new policy on hospital performance. The main impact measure was a national casemix index, calculated across 2011-2016 using medical discharge and surgical procedure codes. A single-group interrupted time series analysis model with Newey ordinary least squares regression was estimated, including adjustment for seasonality, and stratified by case type. Code-level analysis was used to attribute and explain changes in casemix index due to specific diagnoses and procedures. Results: Our final model included 1,353,025 cases across 146 hospitals with a post-intervention lag-time of two months and seasonality adjustment. Among medical cases the intervention resulted in a positive casemix index trend of 0.11% per month (coefficient 0.002, CI 0.001-0.003), and a level increase of 2.25% (coefficient 0.022, CI 0.005-0.039). Trend changes were attributed to decreased cases of diarrhea and gastroenteritis, abdominal and pelvic pain, essential hypertension and fever of unknown origin. A shift from medium to short-stay cases for specific diagnoses was also detected. Level changes were attributed to improved coding practices, particularly for breast cancer, leukemia and chemotherapy. No impact on surgical casemix index was found. Conclusions: The 2014 policy resulted in increased healthcare effectiveness, by increasing the casemix index of hospitals contracted by the Ministry. This increase was mainly attributed to decreased unnecessary hospitalizations and was accompanied by improved medical discharge coding practices. Integration of pay-for-performance within a healthcare system may contribute to improving effectiveness. Effective hospital regulation can be achieved through systematic collection and analysis of routine data.
Highlights
The linkage of performance and payment has been increasingly used in healthcare during the past two decades
In 2014 the Lebanese Ministry of Public Health (MoPH) changed the basis by which it determined the payment reimbursement tiers of about 140 public and private hospitals, which it contracts for providing hospitalization service coverage for the majority of the Lebanese population
This study investigated the impact of integrating a P4P policy on the complexity of hospitalizations at hospitals contracted by the Lebanese Ministry of Public Health
Summary
The linkage of performance and payment has been increasingly used in healthcare during the past two decades. A pay-for-performance (P4P) framework was integrated within this system, the most prominent component of which was the hospital casemix index (CMI), which reflects the average risk or illness severity of all patients within a hospital (Khalife et al, 2017) This intervention was aimed at improving effectiveness by incentivizing hospitals to decrease unnecessary hospitalizations, as well as to improve fairness in determining hospital reimbursement (by including risk-adjustment), within an integrated evaluation framework. In 2014 the Lebanese Ministry of Public Health integrated pay-for-performance into setting hospital reimbursement tiers, to provide hospitalization service coverage for the majority of the Lebanese population This policy was intended to improve effectiveness by decreasing unnecessary hospitalizations, and improve fairness by including risk-adjustment in setting hospital performance scores. Conclusions: The 2014 policy resulted in increased healthcare version 2 (revision)
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