Practice Payment Research Articles

Commentaries on health services research

Commentaries on health services research

Payments for Watershed Services and Practices in China: Achievements and Challenges

Implementation of payments for watershed services (PWS) has been regarded as a promising approach to coordinating the interests of upstream and downstream ecosystem services stakeholders. There is growing concern about whether PWS programs have achieved their original environmental goals of improving water quality and quantity, as well as the ancillary objective of increasing the welfare of local people. We start with an overview of PWS schemes and focus on their particularity and implementation mechanisms in China. We proceed to review 62 active PWS cases and examine their environmental performance in detail. The resulting findings show that PWS schemes have been able to reduce water pollution to some extent by establishing collaborative upstream/downstream watershed management policies, thereby improving water quality and quantity, as well as by making government officials more responsible for water resource management. In addition, their continued effectiveness in light of present challenges such as water-quality data availability is discussed. Chinese PWS schemes and their implementation mechanisms also provide information useful in monitoring environmental outcomes and guiding future designs of PWS programs in other regions.

Practice funding and socioeconomic deprivation in English general practices: a longitudinal study 2013–2017

BackgroundThe NHS general practice payment formula has no specific measures of socio-economic deprivation, an important health determinant. Variables related to population health needs are poor predictors of cross-sectional variations in practice payments. Additional years of payments data allow longitudinal analyses.AimDo deprivation scores predict variations in the slope over time of NHS practice payments, after adjusting for organisational and population factors?MethodThe sample was 6898 English practices with more than 500 patients, studied over 4 financial years, 2013–2014 to 2016–2017. The dependent variable was total NHS payments per registered patient (after deductions). The independent variable was the Index of Multiple Deprivation (IMD) 2015 score for each practice (range: 3.2 to 66.5). 17 Confounders were selected for conceptual plausibility and data availability at practice level, and included organisational variables and population variables A random intercepts and random slopes model was fitted to adjust for clustering of measurements within practices. The linear effects of independent variables on payments over time were modelled by fitting interaction terms (product of variable with year). Descriptive statistics and univariable analyses were undertaken.ResultsPractice IMD scores were very weak predictors of longitudinal variations in total payments’ slopes (4.9p/patient/1 unit increase in IMD). We also found that our confounders had very small predictive effects, and payments and IMD were not correlated in any year (Spearman correlation coefficients ranging from 0.01 to 0.06). The median of payments increased from £102.77 (2013–2014) to £115.43 (2016–2017).ConclusionTotal payments increased very slightly more in practices with higher deprivation scores. This suggests that the NHS general practice payment formula may not adequately compensate practices whose populations have greater health needs.

Teledermatology in the United States: An Update in a Dynamic Era.

Teledermatology is rapidly advancing in the United States. The last comprehensive survey of U.S. teledermatology programs was conducted in 2011. This article provides an update regarding the state of teledermatology programs in the United States. Active programs were identified and surveyed from November 2014 to January 2017. Findings regarding practice settings, consult volumes, payment methods, and delivery modalities were compared to those from the 2011 survey. Findings from the Veterans Affairs (VA) were reported as an aggregate. There were 40 active nongovernmental programs, amounting to a 48% increase and 30% discontinuation rate over five years. Academia remained the most common practice setting (50%). Median annual consultation volume was comparable with 263 consultations, but maximum annual consultation volume increased (range: 20-20,000). The most frequent payment method was self-pay (53%). Store-and-forward continued to be the most common delivery modality. In Fiscal Year 2016, the VA System consisted of 62 consultation sites and performed a total of 101,507 consultations. The limitations of this study were that consult volume and payment methods were not available from all programs. U.S. teledermatology programs have increased in number and annual consultation volume. Academia is the most prevalent practice setting, and self-pay is the dominant accepted payment method. Innovative platforms and the provision of direct-to-patient care are changing the practice of teledermatology.

PP34 A Cost-Utility Analysis Of The Syncope: Pacing Or Recording Trial

Introduction:For patients with bifascicular block and syncope of unknown origin, different American Heart Association guidelines give Class 2A recommendations for two treatments: the implantable loop recorder (ILR) and empiric pacemaker insertion (PM). Equipoise reflected in guidelines may contribute to uncertainty in management and inefficient resource use. The objective of this analysis is to determine the cost-effectiveness of ILR compared to PM in the management of older adults (age>50 years) with bifascicular block and syncope over two years, from the perspective of a Canadian publicly funded health care system, in the Syncope: Pacing or Recording In ThE Later Years (SPRITELY) trial.Methods:Resource utilization data was collected throughout the trial, and unit costs were assigned (2017 Canadian dollars). Utility was measured at baseline and annually with the EQ-5D-3L. Quality adjusted life years (QALYs) were calculated as area-under-the-curve, and adjusted for baseline imbalances in utility. Confidence intervals for the incremental cost effectiveness ratio were generated with non-parametric bootstrapping.Results:Mean cost in participants randomized to PM was CAD 9,759 (USD 7,400), compared to CAD 13,453 (USD 10,200) in participants randomized to ILR. The ILR strategy resulted in 0.020 QALYs more than the PM strategy. The incremental cost effectiveness ratio was CAD 186,553 (95% CI: −831,950–1,191,816) (USD 141,900, 95% CI: −632,740–906,440) per additional QALY. In 1,000 bootstrapped replicates, the cost of the ILR strategy was always greater than that of the PM strategy. At the threshold of CAD 50,000 (USD 38,000) per additional QALY, the probability that the ILR strategy is the cost effective option is 0.504.Conclusions:ILR costs were greater than PM costs, with little difference in QALY outcomes over two-years. Findings are generalizable to patients similar to SPRITELY participants, from the perspective of the Canadian health care system. However, practice pattern variation and payment systems inhibit generalizability to other countries. Future analysis will explore cost and QALY outcomes in countries that participated in the SPRITELY trial.

Characteristics and Disparities among Primary Care Practices in the United States.

Despite new incentives for US primary care, concerns abound that patient-centered practice capabilities are lagging. Describe the practice structure, patient-centered capabilities, and payment relationships of US primary care practices; identify disparities in practice capabilities. Analysis of the 2015 Medical Organizations Survey (MOS), part of the nationally representative Medical Expenditure Panel Survey (MEPS). Practice-reported information from primary care practices of MEPS respondents who reported receiving primary care and made at least one visit in 2015 to that practice. Surveyed primary care practices (n = 4318; 77% response rate) providing primary care to 7161 individuals, representing 101,159,263 Americans. Practice structure (ownership and personnel); practice capabilities (certification as a patient-centered medical home [PCMH], electronic health record [EHR] use, and x-ray capability); and payment orientation (accountable care organization [ACO] and capitation). Independently owned practices served 55% of patients, hospital-owned practices served 19%, and nonprofit/government/academic-owned served 20%. Solo practices served 25% of patients and practices with 2-10 physicians served 53% of patients. Forty-one percent of patients were served by practices certified as PCMHs. Practices with EHRs cared for 90% of patients and could exchange secure messages with 78% of patients. Practices with in-office x-ray capability cared for 34% of patients. Practices participating in ACOs and capitation served 44% and 46% of patients, respectively. Primary care patients in the South, compared to the rest of the country, had less access to nearly all practice capabilities, including patient care coordination (adjusted difference, 13% [95% CI, 8-18]) and secure EHR messaging (adjusted difference, 6% [95% CI, 1-10]). Uninsured patients were less likely to be served at a practice that used an EHR (adjusted difference, 9% [95% CI, 2-16]). Participants' primary care practices were mostly independently owned, nearly always used EHRs (albeit of varying capability), and frequently participated in innovative payment arrangements for a portion of their patients. Patient practices in the South had fewer capabilities than the rest of the country.

Assessing quality of maternity care in Hungary: expert validation and testing of the mother-centered prenatal care (MCPC) survey instrument

BackgroundInstruments to assess quality of maternity care in Central and Eastern European (CEE) region are scarce, despite reports of poor doctor-patient communication, non-evidence-based care, and informal cash payments. We validated and tested an online questionnaire to study maternity care experiences among Hungarian women.MethodsFollowing literature review, we collated validated items and scales from two previous English-language surveys and adapted them to the Hungarian context. An expert panel assessed items for clarity and relevance on a 4-point ordinal scale. We calculated item-level Content Validation Index (CVI) scores. We designed 9 new items concerning informal cash payments, as well as 7 new “model of care” categories based on mode of payment. The final questionnaire (N = 111 items) was tested in two samples of Hungarian women, representative (N = 600) and convenience (N = 657). We conducted bivariate analysis and thematic analysis of open-ended responses.ResultsExperts rated pre-existing English-language items as clear and relevant to Hungarian women’s maternity care experiences with an average CVI for included questions of 0.97. Significant differences emerged across the model of care categories in terms of informal payments, informed consent practices, and women’s perceptions of autonomy. Thematic analysis (N = 1015) of women’s responses identified 13 priority areas of the maternity care experience, 9 of which were addressed by the questionnaire.ConclusionsWe developed and validated a comprehensive questionnaire that can be used to evaluate respectful maternity care, evidence-based practice, and informal cash payments in CEE region and beyond.

Comprehensive reform of the medical insurance payment practice in Jian′ou city of Fujian province: progress and analysis

This paper introduced the comprehensive reform of the medical insurance payment practice, featuring day/bed payment and clinical visits payment, in Jian′ou city of Fujian province. This reform established a new pattern of two full coverage , i. e., covering all designated medical institutions and all outpatient/inpatient diseases within the city. Centering on population healthcare, such a payment practice encourages changes of the medical institutions, namely to shift from profit drivers to cost control. It also pushes the designated hospitals to improve their quality of care and service efficiency based on a rational limit of medical expenses. These measures have lessened the financial burden of patients, achieving a win-win outcome. Key words: Medical insurance payment reform; Primary management; Day/bed payment; Clinical visit payment

Regional longitudinal healthcare alliances in China: development and policy suggestions

The development status of regional longitudinal healthcare alliances in China was analyzed in the paper. As found by the authors, such existing problems as the healthcare administrative system and fiscal input system, the crisis of confidence on primary medical institutions, poor information platforms, and limited means of medical insurance payment, constitute roadblocks for healthcare alliances to play their roles. Proposals of the paper cover such grounds as follows: the government to make a top-down design and a longitudinal and integrated healthcare system can be built; to build a corporate structure for the alliances, with greater fiscal support; to reform the medical insurance payment practice for integrating interests of medical associations; to clarify the responsibilities of tertiary hospitals, for building a win-win mechanism among stakeholders, and improving the information sharing platform. These measures, if in place, can propel the healthy development of healthcare alliances in China. Key words: Regional longitudinal; Healthcare alliance; Hierarchical medical system; Development status; Policy suggestions

Working Digital Money into a Cash Economy: The Collaborative Work of Loan Payment

This paper examines how different forms of money, specifically digital versus cash, impact on the work of an organisation and its customers. In doing so it contributes to the body of literature exploring how the social meanings of money impact on practice. We describe the findings of an ethnographic study examining loan collection workflows, where bank loans given to auto-rickshaw drivers to purchase their auto-rickshaw are overseen and managed by an intermediary. We found that making the mobile money service usable for the drivers took considerable work and was largely achieved because it was embedded in the wider, trusted, loan payment ecosystem. Although Airtel Money promises anytime, anywhere payments, payment remains time and place bound for the drivers. It is tempting to take a transactional approach to payments, and indeed we initially approached the problem of enabling frequent payments as one of payment mechanism. However, in practice payments are embedded in sets of social relations and a socio-technical ecosystem. It takes considerable collaborative work, and a fair amount of flexibility, to enable these financially vulnerable drivers to pay off their loans, and reducing the issue to one of payment mechanism alone does not tell the full story.

A mixed methods empirical exploration of UK consumer perceptions of trust, risk and usefulness of mobile payments

PurposeThe purpose of this paper is to explore UK consumer perceptions of trust, risk and perceived usefulness of mobile payments through the use of sequential mixed methods.Design/methodology/approachA post-positivist philosophy is used with a social constructionist ontology with a questionnaire as the first survey instrument using an empirical sequential mixed methods approach. Summary quantitative analysis of the questionnaire data is undertaken followed by semi-structured interviews that produce qualitative data on which content analysis is undertaken to assess and explore UK consumer perspectives. The technology acceptance model is used as the underlying framework on which a conceptual model is developed.FindingsUK consumers have significant risk and trust concerns with mobile payments, although these concerns can be overcome when clear consumer benefits are identified whilst bank supported mobile payments have an increased level of trust compared to new market entrants and other established companies. Furthermore, perceived trust positively influences perceived usefulness and mitigates perceived risk, whilst perceived risk negatively influences perceived usefulness. In addition, perceived usefulness significantly and positively influences UK consumer attitude which can lead to adoption.Research limitations/implicationsWhilst 120 completed questionnaire responses are received, only 101 questionnaires are used for analysis. In addition, ten semi-structured interviews are undertaken using a purposeful sample to minimise any imbalance (Oakley, 1981) which increases the reliability of the research findings (Hackley, 2003). This mobile payments research does not have a statistically secure universalisation of the findings, which negates the application of these research findings to other groups and to different social settings (Lincoln and Guba, 1985).Practical implicationsMobile payment organisations will need to focus on identifying the specific benefits of mobile payments to UK consumers as mitigating risk and increasing trust do not compensate for the absence of usefulness.Social implicationsUK consumers indicate a lack of awareness of existing contactless payment guarantees provided by UK banks, although these payment guarantees significantly increase UK consumer trust.Originality/valueBoth quantitative and qualitative empirical data are obtained on UK consumer perspectives of risk, trust and perceived usefulness of mobile payments using sequential mixed methods.

The Oncology Care Model: Perspectives From the Centers for Medicare & Medicaid Services and Participating Oncology Practices in Academia and the Community.

Cancer care delivery in the United States is often fragmented and inefficient, imposing substantial burdens on patients. Costs of cancer care are rising more rapidly than other specialties, with substantial regional differences in quality and cost. The Centers for Medicare & Medicaid Services (CMS) Innovation Center (CMMIS) recently launched the Oncology Care Model (OCM), which uses payment incentives and practice redesign requirements toward the goal of improving quality while controlling costs. As of March 2017, 190 practices were participating, with approximately 3,200 oncologists providing care for approximately 150,000 unique beneficiaries per year (approximately 20% of the Medicare Fee-for-Service population receiving chemotherapy for cancer). This article provides an overview of the program from the CMS perspective, as well as perspectives from two practices implementing OCM: an academic health system (Yale Cancer Center) and a community practice (Hematology Oncology Associates of Central New York). Requirements of OCM, as well as implementation successes, challenges, financial implications, impact on quality, and future visions, are provided from each perspective.

Access to care in cancer: Barriers and challenges.

33 Background: In the current climate of health care reimbursement, coverage reform, and escalating health care costs, navigating cancer care becomes increasingly complex for patients and caregivers. Given the truly fluid marketplace and many payment and care models being established sans engagement with or even information from the patient, it is imperative to assess the ongoing reality of patient access to comprehensive, quality cancer care: care that includes biomedical as well as psychosocial care. Methods: We launched an online research survey project to further explore the cancer patient experience as it relates to accessing health care and living within a new and evolving system of health care. The analysis is based upon a cross-sectional survey of adults (18 years old and older) affected by cancer. The survey was conducted online between June and August of 2016. 1,218 cancer survivors completed survey questions regarding access to insurance, services, and providers as well as direct and indirect costs of care. Results: 78% of patients with cancer either have not or do not recall discussing costs with their health care team prior to treatment. 53.5% of survey respondents reported not knowing the meaning of the term “Clinical Practice Guidelines,” and 73% of participants had never heard the term “Clinical Pathway.” 25% of patients experienced delays in accessing cancer care, 18% of patients reported that costs inhibited them from filling prescription drugs to treat their cancer, 22% of patients chose not to get some of the healthcare services they needed due to high out-of-pocket costs, and 53% reported not receiving social or emotional support. Conclusions: These findings demonstrate that despite progress being made in expanding access to health care, many patients still experience significant barriers and challenges to accessing care. We also find there is a gap in patient knowledge about practice guidelines and payment policies. To create a system where all patients have access to high-quality and comprehensive cancer care, educational efforts are needed to enhance patient understanding of information about practice guidelines and payment policies, including information regarding health risk and benefits, costs, patient health, and quality-of-life outcomes.

Oncology pharmacist opportunities: Closing the gap in quality care.

174 Background: The quality of care provided to oncology patients is beginning to be linked to hospital and practice payment models. Oncology pharmacy specialists are well trained to deliver high-quality oncology care, with a focus on the appropriate utilization and monitoring of medication therapy, patient education and collaboration with other healthcare team members. The extent to which the American Society of Clinical Oncology (ASCO) Quality Oncology Practice Initiative (QOPI) metrics identify specific areas in which pharmacists may enhance care is not known. These findings are important because Centers for Medicare and Medicaid Services designate QOPI as a Qualified Clinical Data Registry (QCDR) and over 1000 US-based oncology practices submit quality data to it. Methods: We reviewed all QOPI measures for potential oncology pharmacist involvement. We utilized a summary of services provided by board-certified oncology pharmacists to identify which services would best fit the care described by the selected QOPI measures. Three individuals identified the areas where pharmacists could contribute and consensus was reached. Metrics were only scored positively for pharmacist impact if they could be obtained via the pharmacist as the primary team member responsible for meeting the measure. Results: Two hundred QOPI quality measures from Fall 2016 were reviewed and 177 were analyzed. Potential areas of pharmacist impact were identified in 67 (38%) of the included metrics. These measures fell within 11 of the 13 possible categories of the service summary. A total of 147 services were identified for the 67 actionable metrics. Patient counseling and education (28%), symptom management and supportive care (23%), chemotherapy adjustment (10%), and participation in protocol-based care (10%) comprised services that most commonly contributed to the ASCO QOPI measure performance. Conclusions: Multiple opportunities exist for pharmacists to directly impact the quality metrics that are measured by the service summary. Focusing new services and patient care activities to address validated quality metrics is a natural next step in the care that oncology clinical pharmacists provide to patients.

How to Create a Successful Lifestyle Medicine Practice.

A lifestyle medicine (LM) practice aims to treat the whole person, with a focus on addressing the root lifestyle causes of disease. Creating a practice in LM comes with an array of challenges. Utilizing different payment systems and practice models, such as cash, traditional insurance, Direct Primary Care model, or concierge systems, allows for the incorporation of more LM services and ensures sustainability in the practice. One must develop a sound business model and aim to keep costs low. Optimizing coding, taking advantage of additional LM services, and expanding service formats to group visits or telemedicine are all creative ways to incorporate and develop LM practices. Anticipation of new challenges and flexibility in practice models and payment systems allows one to be successful in starting or transitioning to an LM practice.

Population health needs as predictors of variations in NHS practice payments: a cross-sectional study of English general practices in 2013-2014 and 2014-2015.

BackgroundNHS general practice payments in England include pay for performance elements and a weighted component designed to compensate for workload, but without measures of specific deprivation or ethnic groups.AimTo determine whether population factors related to health needs predicted variations in NHS payments to individual general practices in England.Design and settingCross-sectional study of all practices in England, in financial years 2013–2014 and 2014–2015.MethodDescriptive statistics, univariable analyses (examining correlations between payment and predictors), and multivariable analyses (undertaking multivariable linear regressions for each year, with logarithms of payments as the dependent variables, and with population, practice, and performance factors as independent variables) were undertaken.ResultsSeveral population variables predicted variations in adjusted total payments, but inconsistently. Higher payments were associated with increases in deprivation, patients of older age, African Caribbean ethnic group, and asthma prevalence. Lower payments were associated with an increase in smoking prevalence. Long-term health conditions, South Asian ethnic group, and diabetes prevalence were not predictive. The adjusted R2 values were 0.359 (2013–2014) and 0.374 (2014–2015). A slightly different set of variables predicted variations in the payment component designed to compensate for workload. Lower payments were associated with increases in deprivation, patients of older age, and diabetes prevalence. Smoking prevalence was not predictive. There was a geographical differential.ConclusionPopulation factors related to health needs were, overall, poor predictors of variations in adjusted total practice payments and in the payment component designed to compensate for workload. Revising the weighting formula and extending weighting to other payment components might better support practices to address these needs.

Too Burdensome to Bid: Transaction Costs and Pay‐for‐Performance Conservation

AbstractIn a world free of transaction costs, reverse auctions have the potential to cost‐effectively allocate payment for environmental service contracts by targeting projects that provide the most benefit per dollar spent. However, auctions only succeed if enough farmers choose to bid so that the auctioneer can evaluate numerous projects for targeted funding. A 2014 conservation auction to allocate payments for practices that reduce phosphorus runoff in Northwest Ohio experienced very thin bidding. According to a follow‐up survey, auction participation was deterred by the perceived complexity of the bidding process and the need to negotiate with renters. Due to low participation, the actual conservation auction made payments for phosphorus reduction that were surprisingly costly at the margin. Applying a farmer behavioral model to the Western Lake Erie Basin, we simulate participation choice and cost‐effectiveness of environmental outcomes in reverse auctions and uniform payment conservation programs. Results reveal that when perceived transaction costs of bid preparation are high, reverse auctions can be less cost‐effective than spatially targeted, uniform payment programs that attract higher participation.

Discussion on the outcomes of the"Settlement by disease scoring"reform in medical insurance of Yinchuan

An introduction to the background of theSettlement by disease scoringpolicy in Yinchuan, concept and principles of the policy, and the medical insurance payment practice according to this policy.The authors compared the year-end settlement of medical insurance of a tertiary hospital in Yinchuan before the policy came into practice, expense growth per visit for inpatients of medical insurance, ratio of reimbursement, and ratio of complete out-of-pocket payment.These data were analyzed regarding the merits of such a policy and problems incurred, along with recommendations. Key words: Yinchuan; Medical insurance; Payment; Settlement by disease scoring; Merits

Designing incentive pay practices to motivate not alienate: why firms adopt different payment practice configurations in different countries

Purpose Examines the reward structures used by private-sector firms in different locations. Design/methodology/approach Analyzes the prevailing incentive pay practice configurations in 14 countries over four continents. Investigates the extent to which local factors constrain firms’ use of personal and team bonuses or profit-sharing. Findings “When in Rome, do as the Romans do” – an old saying but still relevant for the growing number of firms operating in several countries. A well-thought-out incentive scheme encourages employees to think and act in ways that support company objectives. But people in different places can have different ideas about what is fair and appropriate. Human resource professionals have to decide whether to follow the local norms or to introduce the firm’s established practices – and an informed decision can make the difference between having a motivated workforce or making an expensive mistake. Practical implications Observes that organizations in some countries show a strong preference for a particular bundle of incentive options. Warns that introducing a different approach may prove counter-productive unless combined with a careful process of change management. Social implications Highlights the importance of institutional context and social norms in determining the incentive pay configurations adopted in different countries. Originality/value Provides an international guide to prevailing patterns of incentive payment adoption. Shows that external constraints specific to individual countries can have a significant impact on the flexibility of incentive system design.

Implementing MACRA: Implications for Physicians and for Physician Leadership.

This Viewpoint discusses the Medicare Access and CHIP Reauthorization Act and the key features of the law and the opportunities it presents to shape the future of payment and medical practice.