The PROMETHEUS bundled payment experiment: slow start shows problems in implementing new payment models

Fee-for-service payment is blamed for many of the problems observed in the US health care system. One of the leading alternative payment models proposed in the Affordable Care Act of 2010 is bundled payment, which provides payment for all of the care a patient needs over the course of a defined clinical episode, instead of paying for each discrete service. We evaluated the initial "road test" of PROMETHEUS Payment, one of several bundled payment pilot projects. The project has faced substantial implementation challenges, and none of the three pilot sites had executed contracts or made bundled payments as of May?2011. The pilots have taken longer to set up than expected, primarily because of the complexity of the payment model and the fact that it builds on the existing fee-for-service payment system and other complexities of health care. Participants continue to see promise and value in the bundled payment model, but the pilot results suggest that the desired benefits of this and other payment reforms may take time and considerable effort to materialize.     

Multilevel models and health economics

Multilevel analyses have become an accepted statistical technique in the field of education where over the past decade or so the methods have been developed to explore the relationships between pupil characteristics and the characteristics of the schools they attend. More recently, widespread use has extended to other social sciences and health research. However, to date, little use has been made of these techniques within the health economics literature. This paper presents an introductory account of multilevel models and describes some of the areas of health economics research that may benefit from their use. © 1997 John Wiley & Sons, Ltd.     

Cost-control and medical specialist payment: the Dutch alternative

The fee-for-service system is a growing problem for insurers and governments. The main reason for this is the open-ended character of this system which makes cost-control a very difficult task. The pressures on the fee-for-service system are becoming more pronounced, especially in countries such as Canada, Germany and the Netherlands which use budget restrictions on national health care expenditure (macro caps). In these countries policy makers are searching for an alternative payment system and an appropriate definition of a corresponding status for doctors. The alternative, however, does not have to lead automatically to a salaried status of doctors in the hospital organization. The Dutch experience of the change of the payment system for medical specialists illustrates the transition to a new 'negotiated order'. The introduction of the 'lump sum' and the sub-contractor relationship with the insurance companies leaves the organizational autonomy of medical specialists intact. In exchange the medical specialists cooperate with the insurers in trying to control the costs of health care. In this process of strategic change, two factors are very significant, i.e. the new leadership of the local medical specialists and the governmental 'circumvention' of the powerful associations of doctors and insurers.     

Detecting bad actors in value-based payment models

Health Services and Outcomes Research Methodology - The U.S. federal government is spending billions of dollars to test a multitude of new approaches to pay for healthcare. Unintended consequences...     

Comparing alternative risk-adjustment models

The use of mental health indicators to compare provider performance requires that comparisons be fair. Fair provider comparisons mean that scores are risk adjusted for client characteristics that influence scores and that are beyond provider control. Data for the study are collected from 336 outpatients receiving publicly funded mental health services in Washington State. The study compares alternative specifications of multiple regression-based risk-adjustment models to argue that the particular form of the model will lead to different conclusions about comparative treatment agency performance. In order to evaluate performance fairly it is necessary to not only incorporate risk adjustment, but also identify the most correct form that the risk-adjustment model should take. Future research is needed to specify, test, and validate the mental health risk-adjustment models best suited to particular treatment populations and performance indicators.     

Comparison of alternative regression models for paired binary data

We used simulated data, derived from real ophthalmologic examples, to evaluate the performance of alternative logistic regression approaches for paired binary data. Approaches considered were: standard logistic regression (ignoring the correlation between fellow eyes, treating individuals classified on the basis of their more impaired eye as the unit of analysis, or considering only right eyes); marginal logistic regression models fitted by the maximum likelihood approach of Lipsitz, Laird and Harrington or the estimating equation approach of Liang and Zeger; and conditional logistic regression models fitted by the maximum likelihood approach of Rosner or the estimating equation approach of Connolly and Liang. Taylor series approximations were used to compare conditional and marginal parameter estimates. Consideration of type I and II error rates found application of standard logistic regression to be inferior to methods that treated the eye as the unit of analysis and accounted for the correlation between fellow eyes. Among these latter approaches, none was uniformly superior to the others across the range of conditions considered.     

From pharmaceuticals to alternative treatments for HIV/AIDS: What is the potential?

The current approach for dealing with the global AIDS pandemic focuses on technology, particularly pharmaceuticals. However, most of the world’s PLWHA (people living with HIV/AIDS) have little or no access to these expensive treatments. Additionally, such technologies have not proven themselves adequate in addressing AIDS in global terms. When the health of communities is prioritised, rather than the interests of pharmaceutical companies and biomedicine, alternative strategies and policies can be considered. These strategies include seriously investigating traditional medicines in other cultures, rather than adopting an uncritical assumption that the biomedical approach is preferable. The limited research available suggests that some alternative treatments could indeed turn out to be useful in treating HIV/AIDS. However, without Western support for rigorous evaluation and development of local alternative therapies, the potential of these treatments for HIV/AIDS will continue to be dismissed. Additionally, the rights of communities to self-determination, and PLWHA to the best possible primary health care, whether in rich or poorer nations, will also be diminished.     

A framework for quantifying net benefits of alternative prognostic models

New prognostic models are traditionally evaluated using measures of discrimination and risk reclassification, but these do not take full account of the clinical and health economic context. We propose a framework for comparing prognostic models by quantifying the public health impact (net benefit) of the treatment decisions they support, assuming a set of predetermined clinical treatment guidelines. The change in net benefit is more clinically interpretable than changes in traditional measures and can be used in full health economic evaluations of prognostic models used for screening and allocating risk reduction interventions. We extend previous work in this area by quantifying net benefits in life years, thus linking prognostic performance to health economic measures; by taking full account of the occurrence of events over time; and by considering estimation and cross-validation in a multiple-study setting. The method is illustrated in the context of cardiovascular disease risk prediction using an individual participant data meta-analysis. We estimate the number of cardiovascular-disease-free life years gained when statin treatment is allocated based on a risk prediction model with five established risk factors instead of a model with just age, gender and region. We explore methodological issues associated with the multistudy design and show that cost-effectiveness comparisons based on the proposed methodology are robust against a range of modelling assumptions, including adjusting for competing risks.     

中国卫生技术评估的发展与挑战

卫生技术评估是一门提供研究证据,改善卫生与决策的应用性学科。随着新技术不断涌现、疾病防治及卫生服务需求不断增加,“健康中国”建设对卫生技术评估的需求日益增长。本文介绍了澳、加、德、法、西、英、泰、韩八国的卫生技术评估应用形式及其主要特点,并在我国卫生技术评估发展的挑战与机遇背景下,探讨了卫生技术评估的国际经验对我国的指导借鉴,及其作为价值评估工具对“健康中国”建设的现实意义。     

Static and dynamic efficiency of irreversible health care investments under alternative payment rules

The paper studies the incentive for providers to invest in new health care technologies under alternative payment systems, when the patients' benefits are uncertain. If the reimbursement by the purchaser includes both a variable (per patient) and a lump-sum component, efficiency can be ensured both in the timing of adoption (dynamic) and the intensity of use of the technology (static). If the second instrument is unavailable, a trade-off may emerge between static and dynamic efficiency. In this context, we also discuss how the regulator could use control of the level of uncertainty faced by the provider as an instrument to mitigate the trade-off between static and dynamic efficiency. Finally, we calibrate the model to study a specific technology and estimate the cost of a regulatory failure.     

The ethical anatomy of payment for research participants

Medicine, Health Care and Philosophy - In contrast to most publications on the ethics of paying research subjects, which start by identifying and analyzing major ethical concerns raised by the...     

Comparison of alternative models for linking drug exposure with adverse effects

Pharmacoepidemiology investigates associations between time-varying medication use/dose and risk of adverse events. Applied research typically relies on a priori chosen simple conventional models, such as current dose or any use in the past 3?months. However, different models imply different risk predictions, and only one model can be etiologically correct in any specific applications. We first formally defined several candidate models mapping the time vector of past drug doses (X (t), t = 1,?…?,u) into the value of a time-varying exposure metric M(u) at current time u. In addition to conventional one-parameter models, we considered two-parameter models accounting for recent dose increase or withdrawal and a flexible spline-based weighted cumulative exposure (WCE) model that defines M(u) as the weighted sum of past doses. In simulations, we generated event times assuming one of the models was correct and then analyzed the data with all candidate models. We demonstrated that the minimum AIC criterion is able to identify the correct model as the best-fitting model or one of the equivalent (within 4 AIC points of the minimum) models in a vast majority of simulated samples, especially with 500 or more events. We also showed how relying on an incorrect a priori chosen model may largely reduce the power to test for an association. Finally, we demonstrated how the flexible WCE estimates may help with model diagnostics even if the correct model is not WCE. We illustrated the practical advantages of AIC-based a posteriori model selection and WCE modeling in a real-life pharmacoepidemiology example.     

Priority setting for pharmaceuticals

Authorities in a number of countries rely increasingly on cost-effectiveness analysis to determine reimbursement status or clinical guidance for pharmaceuticals. This study compared the use of health economic evidence across five reimbursement committees (Australia, Ontario and British Columbia in Canada, Finland, and France) and one clinical guidance committee (England and Wales). Health economic evidence was found to support decision making, although cost-effectiveness is less important in some identifiable situations. Since the relative importance of cost-effectiveness varies, it will be difficult to implement a single explicit threshold. Further research may make patterns of decision making, distributional concerns, and the importance of different criteria more transparent, which would help to narrow the gap between the theory and practice of health economic evaluations. While the use of health economic evidence and the outcome of decision making are similar across committees, there is presently only limited knowledge to what extent prescribing patterns are influenced by decisions.     

The new economics

Current NHS finance mechanisms use activity-based models that do not measure individual services. Economic policies that measure profitability of different services can drive improvement and efficiency. Monitor is looking at the introduction of a requirement for foundation trusts to implement these policies, and will shortly be consulting on the processes involved.     

A systematic review of case-mix models for home health care payment: Making sense of variation

BackgroundCase-mix based payment of health care services offers potential to contain expenditure growth and simultaneously support needs-based care provision. However, limited evidence exists on its application in home health care (HHC). Therefore, this study aimed to synthesize available international literature on existing case-mix models for HHC payment.MethodsWe performed a systematic review of scientific literature, supplemented with grey literature. We searched for literature using six scientific databases, reference lists, expert consultation, and targeted websites. Data on study design, case-mix model attributes, and conclusions were extracted narratively.ResultsOf 3303 references found, 22 scientific studies and 27 grey documents met eligibility criteria. Eight case-mix models for HHC were identified, from the US, Canada, New Zealand, Australia, and Germany. Three countries have implemented a case-mix model as part of a HHC payment system. Different combinations of in total 127 unique case-mix predictors are included across models to predict HHC use. Case-mix models also differ in targeted services, operationalization, and outcome measures and predictive power.ConclusionsCase-mix based payment is not yet widely used within HHC. Multiple varieties were found between HHC case-mix models, and no one best form of a model seems to exist. Even though varieties are partly inevitable due to country-specific contexts, developing a shared vision in case-mix model attributes would be key to achieving efficient, needs-based HHC.