Payment for Performance (P4P): International experience and a cautionary proposal for Estonia

Autorid: Maynard A
Väljaandja/tellija: Eesti Haigekassa, WHO Regional Office for Europe
Märksõnad: tervishoiukorraldus, tervishoiureformid, haiglad, tervishoiutöötajad, finantseerimine
Välja antud: 2008
Tüüp: Uuring/analüüs
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Alamvaldkonnad:Terviseteenuste korraldus, kättesaadavus ja kvaliteet
Kirjeldus: The terms of reference describe the aim of this work as ¿to produce a conceptual paper describing the scope, potential use, alternatives to and limitations of pay for performance (P4P) for providers, particularly concentrating on the hospital sector, and analysing its adaptability to the health care system in Estonia¿. The paper will describe and analyse international experience and its relevance to Estonia, but it is not directly applicable to the Estonian health system. The overall objective is to facilitate further country-specific policy discussions in Estonia building on the international evidence.
The hospital sector is the primary focus of this report. However, performance management of the hospital sector has two overlapping elements. First, managers at the hospital level can be given financial and non-financial incentives to improve performance in relation to adoption of new technology, reducing length of stay and reducing performance variability. This requires managers to negotiate change and to achieve compliance with specialist clinicians, whose influence on resource allocation often dominates behaviour and performance. Second, P4P incentives can be designed and targeted directly at clinical specialists who are then obliged to work with management to comply with EHIF purchaser mandates. A hospital may hit its performance targets but clinical practice within the facility may exhibit unacceptably large variations in clinical behaviour that merit targeted contracting to mitigate internal inefficiency. For instance, a hospital might hit its performance targets but the use of day surgery by its clinicians may vary unacceptably in relation to the evidence base. Behaviour such as this might merit P4P incentives targeted at specialists in addition to those targeted at the hospital.
The first section of the paper will review evidence of common provider problems in all health care systems and their implications for introducing a P4P system. This will be followed by a review of P4P reforms in the United Kingdom and United States in particular. Throughout this analysis, there is an emphasis on the incompleteness of the evidence base and the need for careful experimentation and evaluation to inform service reform. The ultimate goal of P4P reforms is to promote evidence-based care and to ensure that in doing so process management is supplemented by patient-reported outcome measures (PROMs). It is essential to gradually and systematically shift the policy processes from the mere analysis of process or "doing things to patients" to outcome measurement and management to inform decision-makers about whether health care expenditure actually "make patients better".