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 

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Living with dementia

Care Needed. Improving the lives of people with dementia

Across the OECD, nearly 19 million people are living with dementia. Millions of family members and friends provide care and support to loved ones with dementia throughout their lives. Until a cure or disease-modifying treatment for dementia is developed, the progress of the disease cannot be stopped. 

We all know cases of close relatives with dementia, and we understand the suffering that surrounds the disease. OECD has made a good job coping with this difficult topic.
These are the three key chapters:

• Identifying people with dementia 
• Helping people with dementia live well in the community 
• Health and long-term care services for advanced dementia are poor

As people live at home longer, communities need to be better equipped to meet the needs
of people living with dementia. Post-diagnostic care pathways can help connect people with dementia and their families with available services. But communities themselves must also adapt: community-friendly initiatives that train local populations and businesses to respond more effectively to people with dementia can help to reduce stigma around dementia while making the environment safer and more welcoming. Aging at home also means that informal carers will play an important role in supporting people with dementia. Informal carers should receive the support they need, and governments should assess whether existing services for carers are also adequate for carers of people with dementia, who may have unique needs.

Definitely, every country needs to develop a strategy for this disease. Catalonia has already defined its strategy, though resources are not enough.

Jaume Plensa at Madison Square Park

Next generation sequencing is knocking at the door (and the door is open)

Genetic testing: Opportunities to unlock value in precision medicine
Next-Generation Sequencing to Diagnose Suspected Genetic Disorders
Documento de consenso sobre la implementación de la secuenciación masiva de nueva generación en el diagnóstico genético de la predisposición hereditaria al cáncer

This week I've been reading three pieces on the same topic. First, a McKinsey insight on genetic testing, second a NEJM basic article that reviews the whole state of the issue, and third a consensus by three societies on how to implement next generation sequencing .
All of them are required reading for anyone interested in the topic. You'll notice that technology is knocking at the door and we do need to understand how to manage it. Otherwise it will enter anyway (without knocking) and then it will be more value extraction (by others) than value creation (for patients).
Unfortunately, what you'll not find in these articles is how to manage the introduction of the technology with organizational patterns, allocation and coordination of tasks and decisions. If you want some clues on this, read my previous post on Geisinger, they are applying what it seems to me the most appropriate perspective.

Sense Sal-Fins que surti el sol