Le recueil en routine de données de santé perçue à l’ère du paiement à la qualité : préconisations de la Commission épidémiologie et santé publique de la SFNDT

In France, the method of financing is mainly based on the quantity of care produced. The fixed-rate financing of patients with chronic kidney disease at stage IV or V introduces the notion of payment to quality. Part of the quality assessment will focus on the patients’ feelings about their care. The objective of this paper is to assess these indicators used in nephrology, markers in their own right of the quality of care. The patients reported outcomes measures considering the impact of illness or care and the Patient Reported Experience Measures considering their perception of their experience with the health care system or care pathway, are broader than quality of life. These PROs are measured using standardized and validated questionnaires, generic or specific. The Standardised Outcomes in Nephrology initiative has shown that PROs, too often neglected in favor of biological criteria, are instead favored by patients. In the context of a broad deployment of monitoring the quality of life for the purpose of evaluation of care, outside research protocol, the Commission recommends one of the following 2 tools: EuroQol 5D and 12-Item Short Form Health Survey, a compromise between feasibility and relevance and e-SATIS given its great use in health facilities, with an annual follow-up.     

Who had access to doctors before and after new universal capitated subsidies in New Zealand?

In 2002, the New Zealand government introduced universal capitated subsidies for general practitioner consultations amid a broader programme of reform intended to reduce inequities in access and encourage more preventive healthcare visits. While consultation numbers increased in the short run, the issue of cost barriers to access has once more garnered significant policy attention, with many commentators concerned that the funding necessary to maintain low fees has not kept up with cost pressures. A longer-term assessment is useful in understanding the relationship between evolving policy conditions and service use.This article explores how the distribution of access to GPs changed in the short and long run using New Zealand Health Survey data from 2002/03 to 2015/16. I find that the capitation subsidies were associated with improved access for indigenous Māori and more preventive visits as intended by 2006/07. However, from 2006/07 onward patients with the greatest health need began reporting fewer and less frequent doctors’ visits per annum. I discuss potential explanations, focussing on the role of capitation subsidies and the successor price-capping scheme. This research contributes evidence to international scholarship on the long-term factors necessary for universal capitated subsidisation to sustainably reduce access inequities, with attention to local nuance.     

Evaluation of a policy to strengthen case management and quality of diabetes care in general practice in Denmark

ObjectivesTo evaluate the utilization of a policy for strengthening general practitioner's case management and quality of care of diabetes patients in Denmark incentivized by a novel payment mode. We also want to elucidate any geographical variation or variation on the basis of practice features such as solo- or group practice, size of practice and age of the GP.MethodsOn the basis registers encompassing reimbursement data from GPs and practice specific information about geographical location (region), type of practice (solo- or group-practice), size of practice (number of patients listed) and age of the GP were are able to determine differences in use of the policy in relation to the practice-specific information.ResultsAt the end of the study period (2007–2012) approximately 30% of practices have enrolled extending services to approximately 10% of the diabetes population. There is regional – as well as organizational differences between GPs who have enrolled and the national averages with enrolees being younger, from larger practices and with more patients listed.ConclusionsOur study documents an organizationally and regionally varied and limited utilization with the overall incentive structure defined in the policy not strong enough to move the majority of GPs to change their way of delivering and financing care for patients with diabetes within a period of more than 5 years.     

如何提高农村基层医疗服务的效率和质量——宁夏新农合门诊按人头预付制改革设计与效果

本研究以宁夏回族自治区为案例,针对村医经济激励水平低下,按项目付费引发不恰当诊治行为,系统内缺乏引导供方提高自身服务效率和质量并促进服务与体系整合协调的经济激励等问题,从供方合理激励的角度出发,对新型农村合作医疗支付制度进行改革设计——以乡村为整体对乡镇卫生院和村卫生室提供的门诊服务实施基于绩效的按人头预付制。随后利用配对整群随机试验设计对改革效果进行评估和检验。研究发现,这一支付制度的实施有效降低了农村基本医疗服务中抗生素的使用率,优化了供方的处方行为,对降低村卫生室的单次门诊费用有一定作用,并且促进服务向村卫生室下沉。本文的政策分析和设计思路及严格的政策评估结果可以为我国支付制度的选择和发展提供政策参考和证据支持。     

Social HMOs and Other Capitated Arrangements for Children with Special Health Care Needs

Objective: Children with special health care needs are increasingly enrolling in managed care arrangements. However, existing managed care organizations, including traditional HMOs, are often poorly suited for caring for this population. In the adult health care area, new managed care entities, called Social HMOs (S/HMO) and Programs for the All-inclusive Care for the Elderly (PACE), have been created to integrate health and health-related services for chronically ill and disabled adults. We describe these models and assess their potential for serving children with special health care needs. Method: We reviewed the literature on managed care for children with special health care needs and evaluation findings from the S/HMO and PACE models for the elderly. Results: Evaluations of the S/HMO and PACE models have yielded mixed findings. Some of the more positive accomplishments include lower use and expenditures for long-term care services compared to other demonstration projects, greater integration of primary care physicians in decision making concerning long-term care, and improved management of transitions between care levels. On the negative side, start-up has been slow, prospective members have been hesitant to enroll, intermittent and sometimes frequent operating deficits have emerged, no discernible positive effects on health or social outcomes are apparent, and no significant overall savings have emerged. Conclusions: With mixed results so far, caution is required in applying these or similar models for vulnerable child populations. However, given the inadequacies of traditional managed care for this population, we believe experimentation with new models of care that integrate health and health-related services is important. Such experimentation should be fostered only to the extent that the models are carefully designed and then implemented in a manner that protects the interests of children with special health care needs.     

泰国全民健康覆盖经验及对我国的启示

本文介绍了泰国全民健康覆盖的经验及其对中国的启示。泰国于2001年通过"30泰铢计划"实现了全民健康覆盖。泰国全民健康覆盖显著的特点表现在三个方面,分别是区域医疗联合体为基础的服务提供体系,强调基层医疗卫生服务的核心作用,以及通过按人头支付等措施合理配置卫生资源。有研究证据表明泰国实施全民健康覆盖后,卫生系统绩效得到显著改善。我国在实现全民健康覆盖的过程中,可借鉴泰国经验,加强政府的政治承诺,强化基层卫生服务体系建设,开展协调的综合改革。     

Effects of different remuneration methods on general medical practice: a comparison of capitation and fee-for-service payment.

There are severe methodological problems to be overcome in comparing the effects of different payment methods on general medical practice, not least because there are many factors which affect the pattern of service delivery. Also, the reliability and comparability of data may be poor. This article emphasises that the effects of capitation and fee-for-service payment methods on general medical practice should be carefully compared with factual information, especially numerical data. In so doing, it is shown that there are supporting data for the contention that a fee-for-service system encourages more consultations, more diagnostic tests, higher drug use, higher surgical rates and higher costs than a capitation system. On the other hand, a capitation system may lead doctors to hastier and less courteous care than a fee-for-service system. The geographical distribution of general practitioners (GPs) may be more even, and continuity of care may be better maintained, under a capitation system; but there may be excessive referrals from GPs to specialists under this system of payment. There is no evidence for the contention that a capitation system encourages preventive medicine, but the financial coverage for preventive procedures does encourage such procedures.     

Risk-adjusted capitation funding models for chronic disease in Australia: alternatives to casemix funding

Under Australian casemix funding arrangements that use Diagnosis-Related Groups (DRGs) the average price is policy based, not benchmarked. Cost weights are too low for State-wide chronic disease services. Risk-adjusted Capitation Funding Models (RACFM) are feasible alternatives. A RACFM was developed for public patients with cystic fibrosis treated by an Australian Health Maintenance Organization (AHMO). Adverse selection is of limited concern since patients pay solidarity contributions via Medicare levy with no premium contributions to the AHMO. Sponsors paying premium subsidies are the State of Victoria and the Federal Government. Cost per patient is the dependent variable in the multiple regression. Data on DRG 173 (cystic fibrosis) patients were assessed for heteroskedasticity, multicollinearity, structural stability and functional form. Stepwise linear regression excluded non-significant variables. Significant variables were ‘emergency’ (1276.9), ‘outlier’ (6377.1), ‘complexity’ (3043.5), ‘procedures’ (317.4) and the constant (4492.7) (R²=0.21, SE=3598.3, F=14.39, Prob<0.0001. Regression coefficients represent the additional per patient costs summed to the base payment (constant). The model explained 21% of the variance in cost per patient. The payment rate is adjusted by a best practice annual admission rate per patient. The model is a blended RACFM for in-patient, out-patient, Hospital In The Home, Fee-For-Service Federal payments for drugs and medical services; lump sum lung transplant payments and risk sharing through cost (loss) outlier payments. State and Federally funded home and palliative services are ‘carved out’. The model, which has national application via Coordinated Care Trials and by Australian States for RACFMs may be instructive for Germany, which plans to use Australian DRGs for casemix funding. The capitation alternative for chronic disease can improve equity, allocative efficiency and distributional justice. The use of Diagnostic Cost Groups (DCGs) is a promising alternative classification system for capitation arrangements.     

医疗费用供方支付方式比较研究

本文通过比较预算支付、按人头支付、按服务项目支付和按病种补偿的优缺点,得出:任何支付方式都有正负两方面的作用,将几种支付方式结合起来的支付方式可能抵消各自的缺点,从而可以构造出较好的支付方式。