Alignering van zorg betalingssystemen met de performantie van het gezondheidszorgsysteem. Een vergelijking tussen evidence, objectieven en preferenties

Increasing health care needs and new technology put long term sustainability of western health systems as they currently operate, into question. One instrument to redesign the health system is the reform and purposive use of supply side financial incentives, which are inherent to (mixed) healthcare payment systems. There is room for improvement in quality of care performance. Therefore, incentives that reduce overuse, underuse and misuse may be a way forward to improve sustainability and overall performance, with as few unintended consequences as possible. Using a systematical approach to policy at the health systems level, we examine whether the closer alignment of theoretical predictions, evidence for best results, the maximization of total benefit from objectives’ fulfillment, and care payment preference according to care typology, is expected to improve health system performance. The study consists of four phases. In a first phase, we laid the theoretical and empirical foundation bydeveloping a behavioral performance model, a practical care payment implementation model (MIMIQ), and by conducting a meta-review and a systematic review of care payment system interventions, their effects and contextual dependencies. Model predictions and empirical findings confirm that performance based payment and prospective payment, if designed appropriately in line with supported key objectives within a particular context, improve those objectives (health gain, best practice, coordination, cost containment, etc.) relatively more, compared to fee for service or salary use. However, unintended consequences cannot completely be avoided,hence the importance of mixing multiple care payment systems. There is scant evidence for the latest versions of performance based payment (shared savings, warranty use, etc.). Secondly, using a discrete choice experiment, we tested the hypothesis that aligning the objective function of physicians with health improvement, through mixed payment with aperformance based component, increases buy-in of reforms and rebalancestotal benefit for high intensity specialties (surgery) towards relatively lower intensity specialties (general practice), based on the value ofservices. We compared physician findings with the estimated benefit forpolicy makers, healthcare executives and researchers across Canada, Oceania, the United States, and Eastern and Western Europe. The results suggest that (a) moving from current payment systems to a (partially) valuebased payment system is supported by physicians, despite a provider wellness trade-off, if effectiveness of care and long term cost improve. (b) Co-depending on especially coordination, innovation, and patient centeredness effects, total benefit for general practitioners increases, whereas total benefit for surgeons decreases. (c) Physicians as a whole gainin terms of objectives’ fulfillment in Eastern Europe and the US, but not in Canada, Oceania and Western Europe. Finally, (d) such payment reform more closely aligns the overall fulfillment of objectives, between physicians, policy makers and healthcare executives. Thirdly, we tested the hypothesis that care typology (being predictable and evidence informed versus being unpredictable and complex) guides healthcare payment preferences of physicians, policy makers, care executives and researchers. We collected survey data from 942 stakeholders across Canada, Europe, Oceania and the United States. Forty eight international societies invited members to participate. Two ‘extremes’ were discerned: (1)dominant preferences of physicians, who hold on to FFS, even when this precludes the advantages of other payment systems, with a minimal risk of harm (OR 1.85 for primary prevention; OR 1.89 for service line, compared to non physicians), and (2) the support of managers for quality bonusor adjustment (OR 1.92), and researchers for capitation (OR 2.05), evenwhen this could cause harm. Payment reform will proof to be difficult, as long as physicians, managers and researchers misalign payment systemswith care typology. Fourthly, we turned from care payment to reimbursement decision making as a point of comparison. We examined six cases of reimbursement decision making at the national health insurance authority in Belgium, with outcomes that were contested from an evidence-based perspective. In depth interviews with key stakeholders allowed us toidentify the relative impact of clinical and health economic evidence; financial impact & resources; values, ideology & political beliefs; and other factors. Next to evidence, numerous other criteria were perceived to influence reimbursement policy. These included considerations that stakeholders deemed crucial in this area, such as taking into account the cost to the patient, and managing crisis scenarios. However, negative impacts were also reported, in the form of bypassing regular procedures unnecessarily, dominance of an opinion leader, using information selectively, and influential conflicts of interest. ‘Evidence’ and ‘negotiation’ are both essential inputs of health policy. A more purposively aligned approach to both reimbursement and care payment decision making may support the health system in what is truly innovative and value for money, while reducing overuse, underuse and misuse. We conclude that theory, evidence, total benefit alignment, and the comparison with reimbursement decision making, all support moving ahead with proposed care payment reform. However, context specific demonstration projects, guided by local objectives, should inform policy in those health systems that lag behind in widening the goals for financial incentive use. We formulated policy recommendations with respect to priority setting (medical conditions’ full care cycles), mixed payment design (care typology alignment) and external support conditions. The study contributed to this research domain in multiple ways. We reinforced both the conceptual basis and evidence based input of existing formalized models of supply side financial incentive use. Performance based payment in particular, wasunderdeveloped in this area. We provided new insights in which objectives, to what degree, are important to healthcare stakeholders. We demonstrated the usefulness of innovative methods, such as a discrete choice experiment. Finally, we looked into the limits of information driven reforms, by focusing on care typology. The reimbursement cases showed that many insights can interchangeably be transposed across related health policy domains. With this study, we hope to have made a contribution to build those values and objectives into the system that drive healthcare stakeholders, and the society as a whole. Future studies should (1) address the external validity of our findings within specific contexts of health systems, care settings, and specialties, and (2) includethe perspective of citizens and patients.

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