Payment By Results Research Articles

Can payment by results ensure equitable access to contraceptive services? a qualitative case study

BackgroundThe Leave No One Behind (LNOB) agenda compels sexual and reproductive health and rights (SRHR) implementers to focus on the multiple and intersecting forms of discrimination and inequalities. One strategy to address these is Payment by Results (PbR). Using the Women’s Integrated Sexual Health (WISH) programme as a case study, this paper examines if and how PbR can ensure equitable reach and impact.MethodsGiven the complexity of PbR mechanisms, a theory-based approach was used in the design and analysis of this evaluation, drawing on four case studies. These were conducted by reviewing global and national programme data and by interviewing 50 WISH partner staff at national level and WISH programme staff at global and regional levels.ResultsThe case studies found that inclusion of equity-based indicators in the PbR mechanism had demonstrable effects on people’s incentives, on how systems work, and on modes of working. The WISH programme was successful in achieving its desired programme indicators. The use of Key Performance Indicators (KPIs) clearly incentivised several strategies for service providers to innovate and reach adolescents and people living in poverty. However, there were trade-offs between performance indicators that increased coverage and others that increased equitable access, as well as several systemic challenges that limited the possible incentive effects.ConclusionsThe use of PbR KPIs incentivised several strategies to reach adolescents and people living in poverty. However, the use of global indicators was too simplistic, resulting in several methodological issues.

Payment by results in international development: Evidence from the first decade

AbstractPayment by results is a relatively new way of giving development aid, where a recipient's performance against pre‐agreed measures determines the amount of aid they receive. Advocates for the mechanism argue it provides donors with both a ready justification for maintaining aid budgets and better results through innovation and autonomy. It has proved popular, with most bilateral aid donors having at least experimented with the mechanism and the variety of measures stretching from individual health workers being paid for each procedure, to national governments being paid for students' test scores. However, there has not been a robust assessment of whether Payment By Results (PbR) achieves its aims for greater effectiveness. I synthesize the evidence from eight projects fully or partially funded by DFID, the recognized world leader on PbR. This represents the best evidence currently available, and is critically analysed using the leading theoretical framework that breaks each agreement into its constituent parts. I find no evidence that PbR leads to fundamentally more innovation or autonomy, with the overall range of success and failure broadly similar to other aid projects. This may partly be due to the current use of Payment by Results, with no readily identifiable examples of projects that truly meet the idealized PbR designs. Advocates of PbR may thus conclude the idea is yet to be tested. I argue PbR does not deal with the fundamental constraints that donors face, and so it is unsurprising that PbR is subject to the normal pressures that affect all aid spending.

Mental Health Integration Past, Present and Future: National Survey into Mental Health Integration in England

Mental health services have undergone radical transformation in the past 30 years. A community based care model has largely replaced the acute and long term care provided in large institutions. This research seeks to examine the transformation of mental health services in England and the relevance to current policy with particular emphasis on the integration of health and social care within mental health services. Through the use of a comprehensive survey of a range of professionals, and interviews with local and national leaders across England involved in both mental health provision and social care, along with a review of published literature, this paper seeks to explore the context and factors that are affecting integration between health and social care in mental health. In 1999, the Government launched a major programme of change and modernisation in mental health services within England with the NSF for Mental Health. What has followed was an expansion of mental health services and an increasing focus on both service user experience and quality of provision. Through numerous iterations of public policy in the subsequent 15 years, there has been a coming together of health and social care provision within mental health firstly facilitated by section 31 of the 1999 Health Act and subsequently by section 75 of the National Health Service Act 2006. Combined, both Acts facilitated the transfer or secondment of social care staff to NHS bodies and the transfer of health related functions of local authorities to NHS bodies that are 'likely to lead to an improvement in the way in which those functions are exercised‟. Throughout England services have generally moved closer together through various levels of integration, ranging from co-location, shared management and information systems without formal s75 agreements to full integration with formal s75 agreements and governance. The objective was to deliver enhanced service experience to service users, improving the quality of care and reducing isolated or silo working. The experience of integration has been as varied as the numerous locations affected. Over the past decade new statutory duties of local authorities have emerged along with changing policy: Mental Capacity Act 2005 followed by the Deprivation of Liberty Safeguards, policies relating to adult safeguarding subsequently enshrined into duties within the 2014 Care Act and the drive to personalisation, prevention and recovery. All these are against a background of significant cuts to local authority budgets. Within mental health services there has been the emergence of Payment by Results (PbR), of enhanced patient safety and quality measures centred on Care Programme Approach, of an increasingly competitive environment between providers and an approximate 8% cut to NHS mental health funding (BBC News March 2015). This changing policy and economic environment has placed significant tensions on local working arrangements between the NHS and local authorities in mental health services, leading to numerous revisions of arrangements, with uncertain outcomes.

A critical insight into practitioners’ lived experience of payment by results in the alcohol and drug treatment sector

Since former Chancellor George Osborne described reducing public spending as ‘the great national challenge of our generation’ (Her Majesty’s Treasury, 2010: 12) the UK Government have demonstrated a profound interest in Payment by Results (PbR) as a mechanism to improve service quality, value for money and innovation (Audit Commission, 2012). Although PbR is not a new initiative, it has been rebranded and sold as a vehicle that can steer ongoing strategies for reform, particularly in the field of criminal justice and drug/alcohol treatment (Her Majesty’s Government, 2010; Ministry of Justice 2013). Despite such assertions, the initiative has become synonymous with budget cuts (Community Links, 2015), the privatisation of public services (Policy Exchange, 2013) and controversy. Drawing upon the findings of a focus group with staff who work in a Therapeutic Community, this article highlights the lived experience of practitioners as PbR takes hold of the alcohol and drug treatment sector. The findings suggest that outcome-orientated incentives, such as PbR, hold the potential to transform welfare-orientated sectors into a financial, market-focused milieu.

The Challenges of Outcome Measurement for Arts Practitioners in the Criminal Justice Sector

AbstractArts activities have long been used to help rehabilitate offenders and there is anecdotal evidence to support their transformative power, yet providers have struggled to provide ‘hard evidence’ of their effectiveness. The UK government has introduced Payment by Results (PbR) as a principal component of its public sector reforms. Thus arts projects within criminal justice are now required to engage with an outcomes‐based commissioning process. This article uses an evaluation of the Writers in Prison Foundation (WIPF) to explore the challenges and possibilities presented by this political landscape and to suggest approaches to outcome measurement which will help arts practitioners to survive and flourish.

Justice Reinvestment

The idea of '“Justice Reinvestment'” (JR), has been proposed by United Kingdom (UK) policy makers and criminal justice campaigners as a way of responding to the problems arising from the economic crisis in 2007 and 2008. Despite the interest in JR from policy makers, a systematic approach to JR in the UK has yet to be adopted. Instead, the implementation of JR in the UK has been limited to a somewhat piecemeal approach with an uncoordinated set of initiatives, including Payment by Results (PbR) pilots in England. Featured among these have been criminal justice system re-design and social justice models of JR. While this may have failed to achieve the coherent vision that JR offers, this mixed economy of JR implementation provides learning for the future development of JR in the UK and other jurisdictions contemplating or trialling JR initiatives. Comparing the implementation of JR in the UK with the United States, this paper advances the knowledge base around JR by proposing a universal framework to enable effectiveness comparisons to be made between initiatives, both within and across jurisdictions.

Financial consequences of a payment-by-results scheme in Catalonia: gefitinib in advanced EGFR-mutation positive non-small-cell lung cancer

Background: In 2011 the first payment-by-results (PbR) scheme in Catalonia was signed between the Catalan Institute of Oncology (ICO), the Catalan Health Service, and AstraZeneca (AZ) for the introduction of gefitinib in the treatment of advanced EGFR-mutation positive non-small-cell lung cancer. The PbR scheme includes two evaluation points: at week 8, responses, stabilization and progression were evaluated, and at week 16 stabilization was confirmed. AZ was to reimburse the total treatment cost of patients that failed treatment, defined as progression at weeks 8 or 16.Objective: To estimate the financial consequences of this PbR reimbursement model and determine the perception of the stakeholders involved in the agreement.Methods: Differential drug costs between two scenarios, with and without the PbR, were calculated. A qualitative investigation of the organizational elements was performed by interviewing the parties involved in the agreement.Results: Forty-one patients were included from June 2011 to October 2013 and assessed at two evaluation points. Clinical results were comparable to those observed in the pivotal studies of gefitinib. The difference in the cost of gefitinib using the PbR compared to the traditional purchasing scenario was 6.17% less at 8 weeks, 11.18% at 16 weeks and 4.15% less for the overall treatment. The PbR resulted in total savings of around €36,000 (€880 per patient). From an operational and organizational perspective, the availability of adequate data systems to measure outcomes and monitor accountability and the involvement of healthcare professionals were acknowledged as crucial.Conclusions: Tangible and intangible benefits were identified with respect to the interests of the parties involved. This has led to the incorporation of innovation for patients under acceptable conditions.

Payment by Results in Development Aid: All That Glitters Is Not Gold

Payment by Results (PbR), where aid is disbursed conditional upon progress against a pre-agreed measure, is becoming increasingly important for various donors. There are great hopes that this innovative instrument will focus attention on ultimate outcomes and lead to greater aid effectiveness by passing the delivery risk on to recipients. However, there is very little related empirical evidence, and previous attempts to place it on a sure conceptual footing are rare and incomplete. This article collates and synthesises relevant insights from a wide range of subfields in economics, providing a rich framework with which to analyze Payment by Results. I argue that the domain in which it dominates more traditional forms is relatively small and if it is used too broadly, many of the results it claims are likely to be misleading. The likelihood of illusory gains stems from the difficulty of using a single indicator to simultaneously measure and reward performance: ‘once a measure becomes a target, it ceases to ...

Payment by results: Challenges and conflicts for the Therapeutic Community

Drawing upon the findings of a 31-month ethnographic study in a residential Therapeutic Community (TC) for substance use, this article sheds light on the challenges and contradictions which surround the introduction of increasingly commercial/business-orientated decisions within the alcohol and drug treatment field. The aim of this article is to critically reflect upon the implementation of an outcome-orientated policy directive, typically referred to as payment by results (PbR), in a residential rehabilitation service, and consider the implications which surround the initiative for those at the coal face of service delivery. The fundamental principles of PbR and the TC are discussed, as are the tensions and dilemmas which surround the implementation of a high-level policy directive that is fundamentally dissimilar to the theoretical ambitions and practice that takes place on the ground in a residential rehabilitation service. To conclude, the article suggests that incentives, with a clear focus on saving money rather than saving lives, provide little more than additional pressures and strains at the coal face of service delivery, transforming individual progression into a financially driven bureaucratic process. The findings not only illustrate the dehumanizing properties of outcome-based payment schemes but bring mainstream representations of effectiveness into sharp focus.

An Approach to Evaluate Payment-by-Results Agreements

Payment-by-Results (PbR) agreements are negotiated by the Italian Medicine Agency (AIFA) with the purpose of minimizing the risk of paying for unsuccessful treatments in the early phases of access when real world utilization evidence is limited. According to such agreements, the manufacturer shall pay back the full drug cost of the therapy in case of early drop-outs due to progression or unsustainable toxicity. This short paper is aimed at showing that a PbR agreement on a new drug is equivalent to an improved evaluation of the drug efficacy, under a payer's perspective. When the National Health Service (NHS) pays the treatment cost only for those patients who are still responding well at a pre-determined timeline, this means that it takes into consideration a sub-population which has a better clinical outcome as compared with the whole eligible population. In other words, the NHS would actually pay for a drug with a higher efficacy than the one which the price negotiation was based on. This argument is supported by a couple of graphical examples, built with data from two clinical studies: GOG-0240 (Avastin®, bevacizumab) and EMILIA (Kadcyla®, trastuzumab emtansine) respectively. The response to therapy is defined in terms of progression-free survival. In a context of economic pressure, PbR is a tool allowing payers to rationalize their spending reducing the risk of paying for unsuccessful treatments, while still funding innovation and therefore increasing the value-for-money.

Awareness of clinical coding: A survey of junior hospital doctors

Background: Clinical coding is an integral part of the NHS and is one of the main methods of gathering clinical data. Since the introduction of payment by results (PbR) in 2004 there has been an increasing emphasis on gathering good quality data to ensure hospitals are being remunerated accurately based on their workload. Method: We conducted a survey of 100 junior doctors looking at their knowledge and awareness of clinical coding. Results: Only 39% of doctors had attended a recent induction programme, and over half felt they knew little to nothing of the clinical coding system. A questionnaire of the coding system highlighted that neither the time since induction nor a self-assessment of knowledge made any difference to the questionnaire score. Conclusion: There is insufficient engagement of junior doctors with the clinical coding process and widespread attitude changes are needed to change this.

‘All this is about is money and making sure that heads are on beds’

The aim of this article is to critically reflect upon some of the practical difficulties which surround the implementation of an outcome-focused payment initiative, colloquially referred to as Payment by Results (PbR), in a drug and alcohol service situated in the North of England. Drawing upon the findings of a longitudinal study in a residential rehabilitation service, the discussion illustrates some of the tensions and dilemmas which surround the introduction of increasingly business-orientated decisions within a person-centered environment that is designed to work alongside some of society’s most troubled and troublesome individuals. To conclude, the article suggests that financially-driven processes (such as PbR) commodify the rehabilitative ideal, making service users and practitioners alike increasingly accountable to a counterintuitive fiscal endeavour.

An Approach to Evaluate Payment-by-Results Agreements

Payment-by-Results (PbR) agreements are negotiated by the Italian Medicine Agency (AIFA) with the purpose of minimizing the risk of paying for unsuccessful treatments in the early phases of access ...

Emergency readmissions to paediatric surgery and urology: The impact of inappropriate coding.

Introduction In England, emergency readmissions within 30 days of hospital discharge after an elective admission are not reimbursed if they do not meet Payment by Results (PbR) exclusion criteria. However, coding errors could inappropriately penalise hospitals. We aimed to assess the accuracy of coding for emergency readmissions. Methods Emergency readmissions attributed to paediatric surgery and urology between September 2012 and August 2014 to our tertiary referral centre were retrospectively reviewed. Payment by Results (PbR) coding data were obtained from the hospital's Family Health Directorate. Clinical details were obtained from contemporaneous records. All readmissions were categorised as appropriately coded (postoperative or nonoperative) or inappropriately coded (planned surgical readmission, unrelated surgical admission, unrelated medical admission or coding error). Results Over the 24-month period, 241 patients were coded as 30-day readmissions, with 143 (59%) meeting the PbR exclusion criteria. Of the remaining 98 (41%) patients, 24 (25%) were inappropriately coded as emergency readmissions. These readmissions resulted in 352 extra bed days, of which 117 (33%) were attributable to inappropriately coded cases. Conclusions One-quarter of non-excluded emergency readmissions were inappropriately coded, accounting for one-third of additional bed days. As a stay on a paediatric ward costs up to £500 a day, the potential cost to our institution due to inappropriate readmission coding was over £50,000. Diagnoses and the reason for admission for each care episode should be accurately documented and coded, and readmission data should be reviewed at a senior clinician level.

The economic implications of the Portsmouth protocol

Background: The underpinning assumption of pay-for-performance (P4P) systems is that providers respond to financial incentives. However, in the UK, the impact of payment-by-results (PbR), a form of P4P, on care is unclear. The objective of this qualitative case study is to understand the local financial dynamics within a system that financially rewards clinical activities. Methods: Staff who acted as decision-makers in a hospital that implemented a quality improvement initiative—‘The Portsmouth Tonsillitis protocol’—were purposively sampled for semi-structured in-depth interviews in July 2014. The interview included questions about knowledge of the protocol, views on financial incentives and other motivations. Findings: Financial gains to the hospital motivated all the participants. Compared to clinicians, administrators were more concerned about the economic implications of their decisions on the hospital. The attitude of individual clinicians towards receiving monetary reward was unclear but they were unequivocal that professionalism, control over bed spaces and patient care were more important motivators of performance. Conclusion: Hospitals are not single entities with a unitary focus but consist of groups that sometimes have dissenting objectives. PbR may have created healthy competition between hospitals; such competition filtered down to clinical teams who vie for bed spaces and revenue with potentially unintended consequences on the wider productivity of the hospital.

Payment by results in forensic mental health.

Forensic mental health services are low-volume, high-cost services. Payment by results (PbR) is the UK s latest attempt to improve efficiency and controls pending behaviours within the secure services. This article discusses the utility of the PbR mechanic in forensic mental health. It explores PbR implementation in non-forensic mental health settings, similar funding processes internationally, and early PbR implementation work in the UK's secure services. Finally, the article discusses the challenges faced when implementing PbR in forensic mental health services and puts forward possible next steps in determining the utility of PbR in forensic mental health.

Delaying the implementation of Payment by Results in mental health: the application of standardisation

Purpose – The purpose of this paper is to explore the issues surrounding a long planned expansion of Payment by Results (PbR) into mental health services and to highlight the factors responsible for the delay. Design/methodology/approach – PbR relies upon “standardisation” of conditions and treatments. This depends upon a scheme of classification that can realistically predict resources required to execute treatment of any one case. Plans to fund NHS mental health services on the basis of tariffs derived in this way have been delayed, and a key reason is the lack of high-quality data. This would require effective “standardisation-to the-average” of both a system of classification and a repertoire of costed treatment pathways. This paper investigated the delay implementation by exploring the difficulties in applying standardisation principles to service provision and tariff calculation. Findings – The paper identified the fundamental difficulty with PbR’s implementation in applying “standardisation” to practice. This is defining the mental disorder that the patient is suffering and designing care pathways at clinical level considering the balance between practical applicability and conceptual/constructional validity. This is necessary to enable the calculation of a national tariff. The conceptual flaws of the Health of the Nation Outcome Scale led to the constructional shortcomings which compromised the credibility and validity of Mental Health Clustering Tool regarding making accurate classification in a standardised way. The validity and credibility of calculating a national tariff thus became contentious on the basis of this inaccurate clinical classification system. Originality/value – This paper explored the driving factors of delay in implementing PbR in mental health through connecting the recent reform with the fundamental assumptions of “standardisation-to the-average”, which provided another perspective to illustrate the current obstacles.

Payment by results: the materialist reconstruction of criminal justice

Purpose – The criminal justice system in England and Wales is being reconstructed on a new operating platform of which Payment by Results (PbR) is the material signifier. This critical historic transformation is occurring during a period of radical economic disruption and political restructuring after 2007-2008. PbR signals the deeper penetration of the core principles of capitalism into the body of the state and its welfare and criminal justice system. Conceptually a Lacanian-Žižekian framework is put to work to theorise these important transformations. The paper aims to discuss these issues. Design/methodology/approach – The design and methodology of this research paper utilises open sources and documentary materials on the development of PbR, in its application primarily to the criminal justice system. Findings – There is evidence that PbR, located within the wider context of capitalist reconstruction, is radically transforming the delivery of criminal justice services. Originality/value – This is the first critical analysis of PbR located within the context of late modern capitalism.

Payment by Results in the UK: Progress to date and future directions for evaluation

In the UK, Payment by Results (PbR) is a central element in public service reform. This policy intention is being translated into practice through programmes of varying designs and scale, operating in multiple areas of policy. There are few completed evaluations of these programmes – although results are starting to emerge – and empirical evidence is lacking. This, combined with the strength of feeling, political imperative and conceptual confusion surrounding PbR, has meant that debate has often been heated and focused on whether or not ‘PbR works’. Within this context, this article examines the role of evaluation in approaching PbR. It argues that evaluation’s focus should be on explanation (looking within programmes; surfacing and testing their theories) and refinement (using findings to improve programmes; using theories to look across programmes) to advance the debate on PbR from ‘for or against?’ to ‘when, how, for whom and under what circumstances?’ The article advocates a Realist approach to this undertaking, setting out an illustrative framework of PbR’s mechanisms and hypothesized outcomes for exploration and development.

HoNOS - their utility for payment by results in mental health.

The purpose of this paper is to present findings from two studies exploring the Health of the Nation Outcome Scale's (HoNOS) utility within a new payment by results (PbR) system for mental health services in England. In the first study principal axis factoring extraction was used to explore a sample of 23,641 HoNOS ratings. In a second study confirmatory factor analysis was used to evaluate four subscale structures on a new sample of 34,716 HoNOS ratings. No HoNOS factor structure evaluated in this study demonstrated adequate fit statistics across several clinical presentations. A new four-factor model was the only structure to achieve fit statistics across all clinical populations, but can only be championed on a "best fit" basis as opposed to "good fit" at the present time. Data used in the current studies relate to six NHS mental health service providers. Replication using a national sample is recommended. Exploration of different HoNOS factor structures for different mental health clusters within the PbR system in England is also recommended. However, it is also possible that removing redundant or adding new items may result in a more stable HoNOS generic factor structure. This is the first HoNOS evaluation as a generic outcome measure for use within a PbR system and provides important insights into its mental health utility and limitations. The findings have significant implications for those developing the national PbR quality and outcomes framework for England's mental health services. However, there are also implications for all nations in which HoNOS is used to report mental health outcomes.