Enciclopèdia de gestió sanitària

 Elgar Encyclopedia of Healthcare Management

 Una enciclopèdia amb aquest índex.

PART I SCENARIOS
1 Big data and artificial intelligence 2
2 Disruptive technology innovations 6
3 Genomics 8
4 Globalization 11
5 Medical tourism 13
6 Precision medicine 16
7 Robotics 19

PART II BASIC MODELS OF HEALTH SYSTEMS
8 Beveridge model 22
9 Bismarck model 24
10 Market-driven model 26

PART III EVOLUTION OF THE PHARMA AND MEDTECH INDUSTRY

11 Market access 30
12 Digital therapeutics 33
13 Biotech 36

PART IV FOUNDATIONS OF HEALTH ECONOMICS

14 Baumol’s cost disease 40
15 Disease mongering 42
16 Moral hazard in health insurance 44
17 Quasi-markets 46
18 Supplier-induced demand 48

PART V FUNDING

19 Payment mechanisms 51
20 Sources of funding 55
21 Tariff vs price 57

PART VI HEALTH POLICY PRINCIPLES

22 Equality and equity 60
23 Universalism 62
24 Well-being 64

PART VII INVESTMENT ANALYSIS

25 Business planning of healthcare services 69
26 Sources of funding for investments 71

PART VIII LEVELS OF CARE

27 Acute, sub-acute and post-acute care 77
28 Chronic care 79
29 Home care and community care 83
30 Hospital 86
31 Long term care 91
32 Prevention 93
33 Screenings 97
34 Primary healthcare 101
35 Secondary vs tertiary vs quaternary care 104

PART IX NEW PARADIGMS

36 Access to healthcare 108
37 Co-production 110
38 Demedicalization 113
39 Evidence-based medicine 115
40 From compliance to concordance 119
41 Gender medicine 121
42 Global health 123
43 Health literacy 125
44 Initiative medicine 127
45 Integrated care 130
46 Population health management 133
47 Skill mix and task shifting in healthcare 136
48 Value-based vs

PART X PLAYERS

49 Boundaryless hospital 142
50 Community and country hospital 144
51 Intermediate and transitional care settings 147
52 Primary care center 150
53 Research hospital 152
54 Teaching hospital 154

PART XI TRENDS

55 Business models 157
56 Decentralization and devolution in healthcare 159
57 Multidisciplinarity and inter- professionality 161
58 Telemedicine 164
59 Vertical and horizontal integration (hub and spoke network) 168

PART XII BEHAVIOURS:

CHALLENGES TO LEADING HEALTH ORGANIZATIONS

60 Accountability 173
61 Accountable care plan and organization 174
62 Iatocracy, professional bureaucracy and corporatization 177
63 Political arena 180
64 Professional vs managerial culture 182
65 Professionalism 184
66 Stakeholder management 186
67 Teamwork 187
68 Turf wars 189

PART XIII PRACTICES

69 Change management 193
70 Disaster management 195
71 Leadership and leadership styles 199

PART XIV ROLES

72 Case manager 203
73 Clinical engineer 205
74 Clinical leader 208
75 Controller 211
76 Family and community nurse 215
77 General practitioner 218
78 Hospitalist 220
79 Medical director 223
80 Operations manager 225
81 Pharmacist 228
82 Quality and risk manager 233

PART XV TOOLS SYSTEM AND

PROCESS: DISEASE MANAGEMENT

83 Clinical governance 237
84 Guidelines and protocols in healthcare systems 239

PART XVI INNOVATION MANAGEMENT

85 Clinical trial 243
86 Health technology assessment 246

PART XVII OPERATIONS

87 Electronic clinical records 251
88 Patient flow logistics 253
89 Patient management 256
90 Supply chain 258
91 Techniques for process and organizations improvement: lean management in healthcare 261

PART XVIII ORGANIZATION

92 Clinical service lines 264
93 Converging trends in hospital transformation 267
94 Divisionalization, clinical directorates and Troika model in healthcare 271
95 Organizational culture 273
96 Organizational design and development for healthcare organizations 276
97 Patient-centered hospital and health organization 281

PART XIX PEOPLE

98 Clinical and professional engagement 285
99 Great Place to Work® 288
100 Magnet hospital 291

PART XX PERFORMANCE

101 Balanced scorecard in healthcare organizations 294
102 Budgeting (financial vs operational) 298
103 Customer satisfaction 301
104 DRG and case mix index 303
105 Length of stay 305
106 Performance measurement and management systems 307
107 PROMs and PREMs 310
108 Strategic control 313

PART XXI PLANNING

109 Strategic planning 318
110 Strategy making 320

PART XXII PROCUREMENT

111 Centralized procurement 324
112 Innovation procurement 327
113 Managed entry agreements (MEA) 330
114 Value-based procurement 333

PART XXIII QUALITY

115 Accreditation in healthcare 337
116 Audit 340
117 Quality management 343

Lliçons sobre política farmacèutica (3)

Regulation, Innovation and Competition in Pharmaceutical Markets

Si voleu un llibre introductori que descriu amb precisió el mercat farmacèutic aquesta és l'opció del moment. Els conceptes habituals necessaris per moure's bé en aquest entorn són explicats amb tots els detalls.

M'ha interessat especialment el tema de pagar per retardar l'entrada dels genèrics, els acords de pagament invers, perquè s'explica amb tota claredat una pràctica vergonyosa de la indústria que ja coneixia però que em faltaven peces.

Es tracta d'això:

‘reverse payment’ patent settlement agreements (also called pay-for-delay settlements), because they provide for the patentee to pay the alleged infringer, rather than the opposite (considering the standard expectation that a defendant would pay a plaintiff to settle), with the aim of delaying its market entry. In other words, in its typical scheme, the brand-name drug pharmaceutical company enters into an agreement with the generic competitor to settle the dispute and to limit its market entry in return for a transfer of value.1 Such transfer can take different forms, including either a direct monetary payment or another form of valuable agreement (eg an authorised licensed entry at a specific date, distribution agreements, favourable terms in a side deal in which the originator company grants a commercial benefit to the generic company), or both. 

Aquest és l'índex del llibre: 

Introduction 1

I. The Different Faces of Pharmaceutical Markets 1

PART I

1. Regulating Entry 15

I. The Main Features of Pharmaceutical Markets: The Supply Side and the Demand Side 15

II. The Product Life Cycle and the Costs of Innovation 20

III. The Access to the Market: Regulatory Approaches 23

A. The European Regulatory Framework 23

B. The US Regulatory Framework 27

IV. Concluding Remarks 33

2. Regulating Exclusivity 34

I. The Interplay between Regulatory Exclusivities and Intellectual Property Rights 34

II. Intellectual Property Rights in the Pharmaceutical Industry: An Overview on the Role of Patents 35

III. EU Supplementary Protection Certificate and US Patent Term Restoration 41

IV. Regulatory Exclusivity 48

V. Research and Bolar Exemptions 52

VI. Exhaustion Doctrine and Parallel Trade 59

VII. Concluding Remarks 63

3. Regulating Prices 64

I. Pharmaceutical Pricing and Reimbursement Systems in Europe 64

II. The US System 70

III. Concluding Remarks 76

viii Contents

PART II

4. Competition Law Enforcement in Pharmaceutical Markets: An Introduction 79

I. EU and US Antitrust Rules: An Essential Overview 79

II. Antitrust Enforcement in the Pharmaceutical Sector 87

III. Market Definition 95

IV. Concluding Remarks 100

5. Reverse Payment Patent Settlements 102

I. The Recurrence of Reverse Payment Patent Settlements in Pharmaceutical Markets 102

II. Reverse Payment Patent Settlements in the United States 105

A. Earlier Case Law and the Actavis Ruling 105

B. Critical Issues after Actavis 109

C. Further Developments 113

III. EU Case Law on Reverse Payment Patent Settlements 119

A. Lundbeck 120

B. Generics 123

IV. Comparative Analysis 127

A. Legal Frameworks 127

B. The Antitrust Assessment 129

V. Concluding Remarks 134

6. Product Hopping 136

I. Pharmaceutical Product Reformulations 136

II. Product Hopping before US Courts 140

III. The EU Experience 146

IV. The Antitrust Assessment of Product Reformulation 151

V. Concluding Remarks 155

7. Excessive Drug Pricing 157

I. The Resurgence of Excessive Pricing Cases in the Pharmaceutical Sector 157

II. Excessive Pricing under EU Competition Law 161

A. Aspen 165

III. The US Approach 169

IV. The Role of Antitrust Enforcement on Excessive Drug Prices 176

V. Concluding Remarks 178

PART III

8. Further Interactions: Pharmaceutical Markets, Intellectual Property and Human Rights 183

I. The Right to Health and Access to Medicines and the Relationship with Intellectual Property Rights: An Overview 183

II. Compulsory Licensing 191

III. Concluding Remarks 196

9. Public Health and Public Interest in Competition Law 198

I. Public Health and Competition Law 198

II. Competition Law and Non-competition Interests 203

III. Concluding Remarks 208

Conclusion 209

Bibliography 213

Index 233

La narrativa de l'assistència sanitària basada en el valor

 Innovative providers’ payment models for promoting value-based health systems: Start small, prove value, and scale up

S'ha parlat molt de l'assistència sanitària basada en el valor i des de fa molts anys. I jo em pregunto, quin sentit tornar a debatre allò que és elemental i fonamental? Si no aporta valor, doncs pleguem d'una vegada. El valor és el que ho justifica. 

I llavors entrem en els sistemes de pagament, que si quan paguem per quantitat no estem pagant pel valor que aportem. Elemental, novament. La dificultat rau en que no tenim mecanismes senzills de mesura de les dimensions que no siguin la quantitat. N'hi ha, però cal anar amb compte.

I així com fa uns dies vaig criticar un document que circula sobre la qüestió, avui vull comentar-ne un altre de l'OCDE que acaba de sortir. Per cert, document encertat amb conclusions semblants a les que feia jo aquí al blog.

El resum, molt resumit:

The publicly available empirical evidence points to modest efficiency and quality gains from value-based payment models. Impact on healthcare spending, outcomes and patient experience varies across programmes. Given the significant variation in the key features of value based payment models and the context-specific issues they address, those models do not offer a onesize- fits-all solution.

Doncs això, tota prudència és poca. Que la narrativa no s'endugui el missatge tot d'una.

 

Sa mar gran a Tossa de Mar, per Dora Maar

Efficient health insurance as a first best

 Sick Insurance: Adverse Selection and Regulation of Health Insurance Markets

When heterogeneity in consumer tastes and needs, and in cost and quality of products, are publically observable, markets can price, sort, and match these variations, and product choices made by consumers yield demand signals that foster efficient resource allocation. These conditions hold, roughly, for a broad swath of economic activity, allowing lightly regulated private markets to successfully approximate allocative efficiency. However, in health care systems around the globe today, participants do not necessarily see the big picture of lifetime health costs and quality of life, and in many systems the incentives that consumers and providers face do not promote efficient allocation of health care resources. Information asymmetries are the fundamental source of difficulties in health insurance markets and in efficient provision of health services. Additional factors contributing to poor performance of health markets include (1) government regulation that is intended to protect the disadvantaged and promote equity, but creates incentives antagonistic to allocative efficiency, (2) inefficient provider organizations and non-competitive conduct, sometimes sheltered by government policies, and (3) behavioral shortcomings of consumers in promoting their own self-interest, including inconsistent beliefs regarding low-probability future events, myopia, and inconsistent risk assessment.

The seminal contributions to economic analysis of Kenneth Arrow, George Akerlof, Joe Stiglitz, Mike Spence, Mike Rothschild, and John Riley establish that when there are information asymmetries between buyers and sellers, adverse selection, moral hazard, and counter-party risk can result, causing markets to operate inefficiently or unravel. Asymmetric information between buyers and sellers, or market regulations that restrict competitive underwriting and force common prices for disparate products, can induce adverse selection. Moral hazard occurs when effort to avoid risks cannot be observed by sellers and stipulated in insurance contracts, and buyers have less incentive for risk-reducing effort when some of their potential losses are covered. When the productivity and cost of medical interventions is not known to all parties, then buyers and third-party-payers may not make informed decisions on therapies. Counter-party risk occurs when sellers evade payment of benefits for losses, or fail as agents to respect the interests of the consumers who are their principals. Adverse selection of buyers with high latent risk or low risk-reducing effort, or sellers with high counter-party risk, make insurance less attractive to buyers, and may cause insurance markets to unravel. Administrative overhead will induce less than full insurance. By itself, this does not make insurance market outcomes inefficient, but increasing returns to scale in administrative costs may lead to an inefficient concentrated market.

In principle, the problems of asymmetric information can be overcome by government operation or regulation of health services; in practice, there remains a major mechanism design problem of designing incentives that handle the asymmetries; e.g., “single payer” systems permit additional levers of control, but information asymmetries cause principal-agent problems even in command organizations. Legal mandates and regulations can make adverse selection worse. Government policy on private health insurance markets often reflects a social ethic that individuals should not be denied health care because of inability to pay, expressed for example in requirements that hospitals admit uninsured patients with life-threatening conditions, and a social ethic that insurance contract underwriting should not be based on risk factors such as gender, race, and pre-existing conditions. When these requirements are not publically financed, they are implicit taxes on insurers and providers that are at least in part passed through to consumers as higher premiums that increase the effective load for low-risk consumers. Both the higher loads and the prospect of public assistance as a last resort reduce the incentive for consumers to buy insurance and to pay (or copay) for preventative care.

The United States has, more than any other developed country, relied on private markets for health insurance and health care delivery. These markets have performed poorly. Denials and cancellations, exclusion of pre-existing conditions, and actuarially unattractive premiums have left many Americans with no insurance or financially risky gaps in coverage. Administrative costs for health insurance in the United States are seven times the OECD average. These are symptoms of adverse selection. Delayed and inconsistent preventative and chronic care, arguably induced by incomplete coverage, have had substantial health consequences: the United States ranks 25th among nations in the survival rate from age 15 to age 60. This impacts the population of workers and young parents whose loss is a substantial cost to families and to the economy. If the U.S. could raise its survival rate for this group to that of Switzerland, a country that has mandatory standardized coverage offered by private insurers, this would prevent more than 190,000 deaths per year.

Given the damage that information asymmetries can inflict on private market allocation mechanisms, the obvious next question is what regulatory mechanisms can be used to blunt or eliminate these problems. This involves examining closely the action of adverse selection and moral hazard, and the tools from principal-agent theory and from regulatory theory that can blunt these actions. There is an extensive literature relevant to this analysis that can be focused on the regulatory design question. Less well investigated are the impacts of consumer behavior, particularly mistaken beliefs. This paper examines these issues, and studies the impacts of regulations intended to promote equity and efficiency. More practically, this paper investigates these issues with reference to the private market in the United States for prescription drug coverage for seniors, introduced in 2006 and subsidized and regulated as part of Medicare.

The efficient regulatory design is mandatory universal insurance, this is the answer. But it has to be eficient, otherwise appears duplicate insurance, paying twice for the same. This is the worst second best, a combined failure of mandatory and private coverage.

Payment systems during the pandemic

 Balancing financial incentives during COVID-19: A comparison of provider payment adjustments across 20 countries

Key messages:

•Públic payers assumed most of the COVID-19-related financial risk.

•Income loss was not a problem when providers were paid by salary, capitation or budgets.

•Providers paid based on activity were compensated through budgets or higher fees.

•New FFS payments were introduced to incentivize remote services.

•Payments for COVID-19 related costs included new fees, per-diem and DRG tariffs.

 Paolo Gasparini at KBR

Payment systems for long-term care

 Pricing long-term care for older persons

Flores M. Increasing beneficiaries and the decline in informal care in the Spanish long-term care system for older persons.
WKC Policy Series on Long-Term Care No. 7: Spain

Further information on this site.

Risk adjustment: a review

 REINSURANCE, REPAYMENTS, AND RISK ADJUSTMENT IN INDIVIDUAL HEALTH INSURANCE

McGuire, Schillo and Van Cleef provide an additional perspective to conventional risk-adjustment. They say:

Reinsurance can complement risk adjustment of health plan payments to improve fit of payments to plan spending at the individual and group level. This paper proposes three improvements in health plan payment systems using reinsurance. First, we base reinsurance payments on spending not accounted for by the risk adjustment system, rather than just high spending. Second, we propose pairing reinsurance for individual-level losses with repayments for individual-level profits. Third, we optimize the weights on the risk adjustors taking account of the presence of reinsurance/repayment.

It sounds good, however technical requirements are demanding to be to implemented.

Payment systems: a review

 Design of financial incentives and payment schemes in healthcare systems: A review

Episode based payments (3)

 Medicare's Bundled Payment Initiatives for Hospital‐Initiated Episodes: Evidence and Evolution

The Impact of Medicare’s Alternative Payment Models on the Value of Care

Bundled payments have been promoted as an alternative to fee‐for‐service payments that can mitigate the incentives for service volume under the fee‐for‐service model. As Medicare has gained experience with bundled payments, it has widened their scope and increased their duration. However, there have been few reviews of the empirical literature on the impact of Medicare's bundled payment programs on cost, resource use, utilization, and quality.

Main messages:

•  Evidence suggests that bundled payment contracting can slow the growth of payer costs relative to fee‐for‐service contracting, although bundled payment models may not reduce absolute costs.
• Bundled payments may be more effective than fee‐for‐service payments in containing costs for certain medical conditions.
• For the most part, Medicare's bundled payment initiatives have not been associated with a worsening of quality in terms of readmissions, emergency department use, and mortality. Some evidence suggests a worsening of other quality measures for certain medical conditions.
• Bundled payment contracting involves trade‐offs: Expanding a bundle's scope and duration may better contain costs, but a more comprehensive bundle may be less attractive to providers, reducing their willingness to accept it as an alternative to fee‐for‐service payment.

Both articles reflect the current situation on payment systems in US. The effort to change fee-for-service is more difficult than expected. There is a lot of money at stake.

 

The Gossips by Norman Rockwell

DRGs 101

 DIAGNOSIS-RELATED GROUPS: a question and answer guide on case-based classification and payment systems

WHO has released a report on DRGs that is useful as introduction to the concept and the design of payment systems.

The document consists of four parts:

Part 1 outlines definitions, terminology and the main conceptual aspects related to CBG and DRG.

Part 2 covers the assessment phase and highlights questions and issues that policy-makers should consider before taking the decision to introduce a CBG system.

Part 3 delves into the preparation phase by exploring policy and design aspects once a country has decided to introduce a CBG system.

Part 4 is concerned with the implementation phase and discusses implementation questions, requirements for system adjustments and the need for monitoring and revision in order to identify and address unintended impacts of a CBG system.

 

 

Spillover effects of payment systems

 Randomized trial shows healthcare payment reform has equal-sized spillover effects on patients not targeted by reform

From PNAS: 

Changes in the way health insurers pay healthcare providers may not only directly affect the insurer’s patients but may also affect patients covered by other insurers.

This is the research question. And this is the result:

We use a payment reform in TM, which was randomly applied to some markets but not others, to study spillovers of healthcare payment reform. We find spillovers of the same sign and similar magnitude on privately insured MA patients. Naturally, our findings are specific to our setting; the existence, sign and magnitude of any spillovers may well vary across contexts.

Sounds good. However, there is a previous research question, which is the insurer's market share that allows to have the option to change the payment system. This former question is as relevant as the later one.

 

Hockney

Episode based payment systems (2)

The Impact Of Bundled Payment On Health Care Spending, Utilization, And Quality: A Systematic Review

THE CURRENT STATE OF EVIDENCE ON BUNDLED PAYMENTS

The topic has already been explained in this blog. Now you may find a systematic review of what is going on in US:

We performed a systematic review of the impact of three CMS bundled payment programs on spending, utilization, and quality outcomes. The three programs were the Acute Care Episode Demonstration, the voluntary Bundled Payments for Care Improvement initiative, and the mandatory Comprehensive Care for Joint Replacement model. Twenty studies that we identified through search and screening processes showed that bundled payment maintains or improves quality while lowering costs for lower extremity joint replacement, but not for other conditions or procedures.

 While bundled payment programs maintain or improve quality while lowering costs for Lower extremity joint replacement, our systematic review suggests that the effects of the payment model on health care spending and utilization varied considerably—particularly by clinical episode type.

So what?. The drivers for success still have to be found. But there is one that is mandatory: payment systems need to be holistic, any partial design will fail. 

Social distance

Episode based payment systems (2)

Value-based provider payment: towards a theoretically preferred design

The details of a payment system methodology are clearly described in this article. I was not surprised to confirm that the proposals we made two decades ago were in the same direction: two-part payment, fix and variable. Unfortunately nowadays we have a retrofuture system that nobody knows exactly how incentives really work. Of course, this is the first best for a discretionary behaviour by a resource allocator. This is a clear step in the wrong direction that started a decade ago. Without proper incentives, efficiency suffers, and to be clear this means less efficient healthcare for the patients. Unfortunately again, nobody cares about it.

The main contribution of this paper is twofold. Inspired by the societal debate on what
stakeholders in health care should ideally strive for, as well as by existing definitions of value, we first described and further specified the concept of value, facilitating the specification of requirements in the design of VBP. We conclude that, in this respect, value is ideally conceptualised as a multifaceted concept, comprising not only high quality of care at the lowest possible costs but also efficient cooperation, innovation and health promotion. Second, starting from these value dimensions, we derived various design features of a theoretically preferred VBP model. We conclude that in order to stimulate value in a broad sense, the payment should consist of two main components that must be carefully designed. The first component is a risk-adjusted global base payment with risk-sharing elements paid to a multidisciplinary provider group for the provision of (virtually) the full continuum of care to a certain population. The second
component is a relatively low-powered variable payment that explicitly rewards aspects of value that can be adequately measured.

The time to fix the current mess has arrived.

Jordi Sàbat

Episode based payment systems

Unraveling the Complexity in the Design and Implementation of Bundled Payments: A Scoping Review of Key Elements From a Payer’s Perspective

After per case based payment systems (DRGs) everybody was waiting for a comprehensive system to measure health services activities. And instead of focusing on episodes, what happened is that bundling was the new frame. Unfortunately, after all these years bundling has not provided the answer because the scope of measurement is related to several diseases and it is not holistic.
When everybody was asking for an alternative to fee-for service, the answer was in my opinion "patient focused episodes of care", but the US government decided otherwise and protected the interests of those that leverage fee-for-service.
Therefore, now it is the time to fix this mistake and take the right  road. In this article you'll find some issues to consider when you have to design a payment system. It still talks about bundling, forget it, substitute it by episodes and it will be fine.

Our framework provides a structured overview of the principal, literature‐based elements of the design and implementation of bundled payment contracts from a payer's perspective. We identified 53 elements that involve all procurement phases and relate to actors on all levels of the health care system. A better understanding of these elements can help payers and other actors devise a strategic approach and reduce the complexity of implementing these contracts. Compared with traditional FFS models, bundled payment contracts introduce an alternative set of financial incentives that affect the entire health care system, involve almost all aspects of governance within organizations, and demand a different type of collaboration among organizations. This is what makes the design and implementation of bundled payment contracts complex and is why they should not be strategically approached by payers as merely the adoption of a new contracting model but, rather, as part of a broader transformation to a more sustainable value‐based health care system, based less on short‐term transactional negotiations and more on long‐term collaborative relationships between payers and providers.

Resource allocation for universal coverage in healthcare

Price setting and price regulation in health care: Lessons for advancing Universal
Health Coverage

Once upon a time Joseph Newhouse said that there are no prices in healthcare. There are some forms of administered prices, tariffs and payment systems. Unfortunately current health economists forget to read some books like "Pricing the priceless", a must read.
Now a new report by WHO and OECD insists again on prices and says:

Pricing health services is a key component in purchasing the benefits package (the covered services) within the overall financing system (Evetovits, 2019). Pricing and payment methods are important instruments in purchasing that provide incentives for health care providers to deliver quality care. A second instrument is contracting, in which the conditions for the payment of services are defined, and prices can be used as signals to providers. A third is performance monitoring. Where health care providers are rewarded based on the outcomes they achieve, these payments also must be priced correctly to provide the right incentives.

Right, there are more elements in the equation than prices, but the tools for fine tunning are too open. Anyway, this report is really welcome and the cases are well described.

Provider payment strategies to improve health

Value-based provider payment: towards a theoretically preferred design

The case for improving health is related, among many things, with the incentive structure of the whole system (people, professionals and providers). If we focus our aim towards providers, then we need to reassess current flaws in the system, and ask what do we have to do. A new article tries to address these issues.

In order to tackle the problems related to current payment methods, worldwide, policymakers and purchasers of care are exploring alternative payment strategies to help steering health care systems towards value . A well-known endeavour in this regard is pay-for-performance (P4P), in which providers are explicitly rewarded for ‘doing a better job’. Although P4P is an appealing idea, explicit financial incentives for value should in principle be used only modestly in provider payment methods because of the multitasking problem. Therefore, it is not surprising that in practice, the majority of provider revenues (typically referred to as the base payment) is not explicitly linked to value. This base payment, however, does create implicit (dis)incentives for value, because each payment method influences providers’ behaviour through incentives.

The article reflects a conceptual framework of key components and design features of a theoretically preferred Value Based Payment method. And the key message is:

We conclude that value is ideally conceptualised as a multifaceted concept, comprising not only high quality of care at the lowest possible costs but also efficient cooperation, innovation and health promotion. Second, starting from these value dimensions, we derived various design features of a theoretically preferred VBP model. We conclude that in order to stimulate value in a broad sense, the payment should consist of two main components that must be carefully designed. The first component is a risk-adjusted global base payment with risk-sharing elements paid to a multidisciplinary provider group for the provision of (virtually) the full continuum of care to a certain population. The second component is a relatively low-powered variable payment that explicitly rewards aspects of value that can be adequately measured.

I fully agree with what they say. Close politicians and officials should take this message into consideration regarding the next primary care physicians' strike, and forget the current confusing approach.

Norman Rockwell 

TIRED SALESGIRL ON CHRISTMAS EVE

Estimate $5,000,000 — 7,000,000

(It may be yours, upcoming auction at Sotheby's)

Enabling Patients to Stick to their Medication

Investing in medication adherence improves health outcomes and health system efficiency

OECD provides some key figures on medication adherence:

Poor adherence is estimated to contribute to nearly 200 000 premature deaths in Europe per year. Patients with chronic diseases are particularly vulnerable to poor health outcomes if they do not adhere to their medications. Mortality rates for patients with diabetes and heart disease who don’t adhere are nearly twice as high as for those who do adhere.

It is estimated to cost EUR 125 billion in Europe and USD 105 billion in the United States per year in avoidable hospitalisations, emergency care, and outpatient visits.

The three most prevalent chronic conditions – diabetes, hypertension, and hyperlipidaemia – stand out as the diseases with the highest avoidable costs, for
which every extra USD spent on medications for patients who do adhere can generate between USD 3 to 13 in savings on avoidable emergency department visits and inpatient hospitalisations alone.

I'm dubious about the exact figures, anyway if you imagine that it is half ow what the say it would be a lot. Systematic reviews say that non-adherence is 15%. This is a hot topic and the ways to tackle are known.

Acknowledge: Medication non-adherence harms health and increases healthcare costs. The first step for the relevant stakeholders is to acknowledge that this problem exists and to adequately recognise its main drivers. Medication adherence needs to move up the policy agenda in order to raise awareness of the problem and mobilise adequate responses.

Inform: Few countries systematically monitor adherence. Routine adherence measures as well as adherence-related quality and performance indicators should be encouraged in order to improve health system effectiveness and efficiency.

Incentivise: Changes in financial incentives for providers and patients are essential. Shifting to payment systems that reward providers for the quality of patient outcomes would provide strong motivation to improve adherence. Medication adherence could also be considered as a measure for performance based contracts with pharmaceutical companies. Where patients’ co-payments for chronic medications exist, their reduction or removal should be considered to reduce financial barriers.

Steer and Support: The adherence process begins with a patient and a prescribing clinician and a dispensing pharmacist who should all be supported by other health system stakeholders. Payers/system designers can develop IT systems that facilitate optimal prescribing and patient-clinician communication or renewing prescriptions by patients. Educators have a role in equipping health professionals with skills in managing adherence such as person centred communication, shared decision-making, and socio-cultural competencies.

Payment systems vs. prices in health care

Payment Methods: How They Work

The problem in health care is not that prices play a role—that is unavoidable. The problem is that prices are distorted in ways that result in inefficient allocation of health care resources. Patients and physicians use too much of health care services that are of low value and not enough of services that are of high value.

This statement refers to US private health care. It may refer to any private health system. The JAMA article reflects an interesting and forgotten issue: The Importance of Relative Prices in Health Care Spending. Data is usually unavailable, and few studies are able to show the implications of relative prices on outcomes.
My impression is that we should review the role of prices in health care and understand better that we do need payment systems, that beyond the standard Hayek signal for producers and consumers, there is a signal of appropriate acces that sends the regulator. This is what some health systems try to apply in public settings, and what we did in Catalonia long ago.
Therefore, the key issue is not to define the method as this report does, though it is necessary. The most important focus should be devoted to the environment and the process that finally will guarantee access and quality of outcomes.

PS. By the way, does anybody know where current payment system in Catalonia stands? Glups!

Behavioral provider payment systems: the next step

Impact of Provider Incentives on Quality and Value of Health Care

Experimenting with incentives for quality is a risky task. The variable requires a precise measure and it must indicate the appropriate signal to the provider to have impact in decisions and behaviour. Usually, rational behaviour is assumed int the models. A recent review highlights this is issue:

Advocates of pay-for-performance in health care maintain that its early failures are the result of inadequate design, a failure to incorporate a more sophisticated understanding of provider motivation into program design (26). On the basis of evidence from early schemes and readings of economic and psychological theory, several researchers have produced blueprints for secondgeneration pay-for-performance frameworks. Their recommendations for designers include making rewards large enough to be meaningful; using penalties in addition to rewards; aligning incentives to professional priorities; using absolute rather than relative performance targets; providing frequent, discrete rewards or punishments; and making an explicit long-term commitment to incentives

But the authors admit that: " Some of these solutions are difficult to implement, are contradictory, or introduce further unintended consequences". And this paves the way to a pessimist view:

Programs are slowly becoming more sophisticated, but unless clear evidence for cost-effectiveness emerges soon, the incentive experiment may have to be abandoned. Many commentators see this abandonment as inevitable, believing incentive programs to be fundamentally flawed. Some concerns are technical in nature and relate to the difficulty of accurately defining and measuring the most important aspects of quality with the greatest impacts on patient outcomes

My impression is that the unit of analysis is usually wrong. Until we are not able to measure patient focused episodes of care properly, in a holistic way, will miss something. This should be the first concern. Of course, this is an overwhelming task, not an easy one.

Camille Pissarro in Sant Feliu de Guixols right now

The priceless conundrum in healthcare

Pricing the Priceless: A Health Care Conundrum

Allocating resources in health care is a pivotal taks and three tools are used to solve it: market, government and professionalism. Briefly, in the market, prices paid would try to reflect information needed to take a decision for the supply side and demand side (hypotetically). Government allocates resources according to information of a benevolent ruler (biased and incomplete information). Professionals decide over the need of care according to "rules and guidelines" and specific patient situation (hypotetically).
As you may imagine, all these three approaches are used everyday in every health system in the world, and unfortunately they are imperfect, basically due to asymetric and incomplete information on one side, and incentives on the other.
Joseph Newhouse wrote a book fifteen years ago, that summarized many of these conundrums. The first is that we don't find prices, we find "administered prices" in health care, those set by insurers (private and public), and:

Setting administered prices is inevitably fraught with error, and because of lags in adapting to technological change, the extent of the error increases as pricing systems age.

This is reason why today we use the term payment systems instead of pricing. Payment systems try to combine different dimensions beyond price, sometimes volume, sometimes quality. Basically they want to correct the error of administered prices.
Unfortunately, the book finishes with a worrying  statement:

This is the conundrum of medical pricing; all arrangements that can be implemented have important drawbacks. Although variation in ideology plays a role in the payment methods that different countries use, the wide variation in institutional arrangements around the world as well as the ongoing efforts at attempting to reform and improve those arrangements in almost every country are consistent with that conundrum.

My impression differs a little bit, it is not and ideological issue. Payment methods differ because risk transfer may be possible or not. In a public system, finally the State assumes all the risk. In a private system, providers  market power may reduce the opportunities to transfer such risk.  Professionals in a public and private system don't assume financial risk, they decide but it is finally transferred to insurers and providers. Nowdays, the issue is still open for debate.