Abstract
BackgroundIn several countries, health care policies gear toward strengthening the position of primary care physicians. Primary care physicians are increasingly expected to take accountability for overall spending and quality. Yet traditional models of paying physicians do not provide adequate incentives for taking on this new role. Under a so-called shared savings program physicians are instead incentivized to take accountability for spending and quality, as the program lets them share in cost savings when quality targets are met. We provide a structured approach to designing a shared savings program for primary care, and apply this approach to the design of a shared savings program for a Dutch chain of primary care providers, which is currently being piloted.MethodsBased on the literature, we defined five building blocks of shared savings models that encompass the definition of the scope of the program, the calculation of health care expenditures, the construction of a savings benchmark, the assessment of savings and the rules and conditions under which savings are shared. We apply insights from a variety of literatures to assess the relative merits of alternative design choices within these building blocks. The shared savings program uses an econometric model of provider expenditures as an input to calculating a casemix-corrected benchmark.ResultsThe minimization of risk and uncertainty for both payer and provider is pertinent to the design of a shared savings program. In that respect, the primary care setting provides a number of unique opportunities for achieving cost and quality targets. Accountability can more readily be assumed due to the relatively long-lasting relationships between primary care physicians and patients. A stable population furthermore improves the confidence with which savings can be attributed to changes in population management. Challenges arise from the institutional context. The Dutch health care system has a fragmented structure and providers are typically small in size.ConclusionShared savings programs fit the concept of enhanced primary care. Incorporating a shared savings program into existing payment models could therefore contribute to the financial sustainability of this organizational form.Electronic supplementary materialThe online version of this article (doi:10.1186/s12913-015-1250-0) contains supplementary material, which is available to authorized users.
Highlights
In several countries, health care policies gear toward strengthening the position of primary care physicians
In the Netherlands, a pilot with a shared savings program for primary care was introduced for a group of primary care providers (in an additional file we provide a brief description of Dutch primary care, see Additional file 1; primary care providers are hereafter referred to as “(pilot) providers”)
We describe a structured approach to designing shared savings programs for primary care, discuss pros and cons of alternative design choices, report on our experience in weighing alternative design choices in reaching a final decision, and discuss opportunities and challenges of operating a shared savings program within a managed competition
Summary
Health care policies gear toward strengthening the position of primary care physicians. Current modes of paying primary care physicians (capitation, fee-for-service, salary) [8] may not be aligned well enough with these policy goals These payment models neither provide the additional resources necessary for maintaining a whole-patient perspective, nor do they incentivize primary care physicians to act upon their role of managing costs and quality across the continuum of care [9]. They may even run counter to these goals [9, 10]. From a theoretical perspective, introducing some form of risksharing in which the insurer shares the risk of achieving high costs or suboptimal value with providers, may help to align interests in a setting where interests tend to diverge [12]
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