Optimal hospital payment rules under rationing by waiting

We derive optimal rules for paying hospitals for non-emergency care when providers choose quality and capacity, and patient demand is rationed by waiting time. Waiting for treatment is costly for patients, so that hospital payment rules should take account of their effect on waiting time as well as on quality. Since deterministic waiting time models imply that profit maximising hospitals will never choose to have both positive quality and positive waiting time, we develop a stochastic model of rationing by waiting in which both quality and expected waiting are positive in equilibrium. We use it to show that, although a prospective output price gives hospitals an incentive to attract patients by raising quality and reducing waiting times, it must be supplemented by a price attached to hospital decisions on quality or capacity or to a performance indicator which depends on those decisions (such as average waiting time, or average length of stay). A prospective output price by itself can support the optimal quality and waiting time distribution only if the welfare function respects patient preferences over quality and waiting time, if patients’ marginal rates of substitution between quality and waiting time are independent of income, and if waiting for treatment does not reduce the productivity of patients. If these conditions do not hold, supplementing the output price with a reward linked to the hospital's cost can increase welfare, though it is possible that costs should be taxed rather than subsidised.     

Strategic Provider Behavior Under Global Budget Payment with Price Adjustment in Taiwan

Global budget payment is one of the most effective strategies for cost containment, but its impacts on provider behavior have not been explored in detail. This study examines the theoretical and empirical role of global budget payment on provider behavior. The study proposes that global budget payment with price adjustment is a form of common‐pool resources. A two‐product game theoretic model is derived, and simulations demonstrate that hospitals are expected to expand service volumes, with an emphasis on products with higher price–marginal cost ratios. Next, the study examines the early effects of Taiwan's global budget payment system using a difference‐in‐difference strategy and finds that Taiwanese hospitals exhibited such behavior, where the pursuit of individual interests led to an increase in treatment intensities. Furthermore, hospitals significantly increased inpatient service volume for regional hospitals and medical centers. In contrast, local hospitals, particularly for those without teaching status designation, faced a negative impact on service volume, as larger hospitals were better positioned to induce demand and pulled volume away from their smaller counterparts through more profitable services and products such as radiology and pharmaceuticals. Copyright © 2014 John Wiley & Sons, Ltd.     

Hospital responses to price shocks under the prospective payment system

Under the prospective payment system (PPS), hospitals receive a bundled payment for an entire episode of treatment based on diagnosis‐related groups (DRG). Although there is ample evidence regarding the impact of the introduction of the PPS, there is little research on the effects of the ensuing changes in payment levels under the PPS. In 2005, the Medicare PPS changed its definition of payment areas from the Metropolitan Statistical Areas to the Core‐Based Statistical Areas, generating substantial area‐specific price shocks. Using these exogenous price variations, this study examines hospital responses to price changes under the PPS. The results demonstrate that, while the average payment amount significantly increases in the affected areas, no parallel trend is observed in admission volume, treatment intensity, and quality of services. Conversely, hospitals facing a price increase are more liable to the perverse incentives that the PPS is known to encourage, namely, selecting or shifting patients into higher‐paying DRGs. These results suggest that paying a higher price for a given service may not induce hospitals to offer services of better quality, but can rather prompt even higher payments through other behavioral responses.     

Using Auctions for Contracting with Hospitals When Quality Matters

This paper analyzes the problem of contracting with hospitals with hidden information when the number of patients wanting treatment depends on the quality of health care services offered. The optimal policy is characterized in the case of a single hospital. It is demonstrated that the regulator can reduce the information rent by decreasing the quality. When the regulator is assumed to be able to organize an auction for awarding the right to provide the service, we characterize the optimal auction and the first score tendering procedure implementing it. The regulator can reimburse a unit price per treated patient and let the hospital choose the level of quality. It is proved that the expected quality of health care services is greater and the expected payment is lower than in the monopoly case.     

我国大型医院床位增长成因分析

近年,我国大型医院床位规模呈持续增长趋势,引发诸如国家医疗服务体系“正三角”结构遭到破坏、医疗费用上涨、优质资源稀释、骨干作用发挥不充分等一系列问题.本研究应用几何模型,将床位规模设为三角形面积,内外因素分别设为三角形的内切外接圆,供方、需方、举办方,分别设为床位规模扩张的作用方,制度因素、市场因素、需求因素和内部管理...     

通过医保支付推进医疗质量管理的经验及启示

目的通过介绍典型国家及地区经验,阐述医保如何通过经济手段促进医疗服务质量提升,供我国大陆地区参考。方法采用文献分析法。采取主题词与分类号组合的检索方式,收集美国、英国及我国台湾地区有关医保与医疗服务质量的文献。结果美国实行基于价值支付的奖惩机制,包括医院服务价值购买计划、再入院扣费计划、医院获得性疾病扣费计划;英国实行提升基层医疗服务质量的激励机制;我国台湾地区实行结合医院评价体系的总额预付制。结论为促使我国大陆地区通过医保支付进一步推进医疗质量管理,建议建设卫生主管部门与医保部门有机融合的医疗质量考核系统,采用质量指标的多元计分方式,设计与质量联动的奖惩机制等。     

地市级公立医院医药价格改革运行现状研究

目的对地市级公立医院药品零差率销售改革情况进行跟踪调研,评价不同阶段性实施效果,为深化和完善医药价格体制改革补充机制提供参考。方法选取2018年1月—2019年12月市级5家医院相关医药价格改革前后运营指标,运用对比研究方法进行改革效果研究。结果样本医院医疗服务收入占比增长,药占比有所下降,运行正常;门诊和住院次均费用不同程度增长;医疗服务价格调整未能有效弥补减少的合理收入,传统内科、肿瘤专科受冲击大。结论落实政府办医主体责任,增加政府财政投入;逐步建立有利于费用控制、以合理成本定价为基础的医疗服务价格动态调整机制;完善医务人员绩效激励机制;探索政府财政对公立医院分类补偿办法;推动DRG付费改革,减少患者的医疗费用负担。     

Do patients choose hospitals with high quality ratings? Empirical evidence from the market for angioplasty in the Netherlands

A necessary condition for competition to promote quality in hospital markets is that patients are sensitive to differences in hospital quality. In this paper we examine the relationship between hospital quality, as measured by publicly available quality ratings, and patient hospital choice for angioplasty using individual claims data from a large health insurer. We find that Dutch patients have a high propensity to choose hospitals with a good reputation, both overall and for cardiology, and a low readmission rate after treatment for heart failure. Relative to a mean readmission rate of 8.5% we find that a 1%-point lower readmission rate is associated with a 12% increase in hospital demand. Since readmission rates are not adjusted for case-mix they may not provide a correct signal of hospital quality. Insofar patients base their hospital choice on such imperfect quality information, this may result in suboptimal choices and risk selection by hospitals.     

临床路径管理与病种付费的关系

按病种付费即固定每个病种服务包的价格,同时规定质量标准,盈亏自负,结余归医院,超支不补。其中,定价和质量控制是两个非常关键的环节。临床路径从过程控制的角度在一定程度上弥补了按病种付费在监管中的盲点,两者相结合可以达到事半功倍的效果。但按病种付费和临床路径管理各有自己的适用范围,超出应用范围后,应采取其他的支付方式和质量监管措施。     

The early experience of a hospital-based pay-for-performance program

This study evaluated the effect of a health-plan-sponsored, hospital-based financial incentive program, focused on heart-failure quality indicators, to improve quality. We conducted separate, hour-long, semistructured group interviews with senior managers and cardiologists at ten hospitals involved in the Participating Hospital Agreement (PHA) program implemented by Blue Cross Blue Shield of Michigan (BCBSM). Under PHA, hospitals are eligible for an annual incentive payment of up to 4 percent of BCBSM's diagnosis-related-group-based inpatient claims, depending on their performance in patient safety, community outreach, and selected quality indicators. Interviews focused on knowledge, perceptions, and impact of pay-for-performance (P4P) strategies. We compared BCBSM-provided data on heart-failure quality indicators between 2002 and 2004 with our qualitative findings. Our analyses suggest that pursuit of incentive-based quality targets may be largely dependent on the context of a particular hospital. In settings where performance did not change, incentives did not appear to drive organizational or individual practice changes. Underperforming hospitals with some of the infrastructure necessary for quality improvement had the greatest success when presented with incentives. We concluded that one formula for a successful P4P program is to direct incentive payment to an organized entity capable of supporting process improvement by applying resources and organizational expertise. In this model, the incentive program supports the organization, and the organization in turn may apply resources to facilitate improvement in clinician performance. Consideration of the requirements of organizations to facilitate improvement in relation to existing quality improvement infrastructure may lead to the future success of hospital-based P4P programs.     

医疗服务供方支付制度改革的挑战与建议

简要回顾了我国医疗服务供方支付方式改革进展,分析了目前医疗服务支付体系面临的主要挑战,包括：医疗服务各方职责关系不明确、缺乏系统的质量标准和质量改进机制以及缺乏对供方的有效激励与引导等。指出单一的支付方式改革无法解决系统问题,必须通过开展系统、综合性改革才能在支付改革领域取得突破;建议推动经办机构成为战略服务购买者,通过需方筹资改善服务绩效,完善支付制度作为医疗保险战略采购政策工具的功能。     

Choice of reserve capacity by hospitals: a problem for prospective payment

This contribution analyzes the impact of prospective payment on hospital decisions with regard to reserve capacity, using Swiss hospital data covering the years 2004–2009. This data set is unique because it permits distinguishing of institutional characteristics (e.g., ownership status) from the mode of payment as determinants of hospital efficiency, due to the fact that some Swiss cantons introduced prospective payment early while others waited for federal legislation to be enacted in 2012. Since a hospital’s choice of reserve capacity depends also on the risk preferences of management while affecting the cost function, heterogeneity is predicted even in the presence of identical technology and factor prices. For estimating hospitals’ marginal costs, we employ the flexible representation of risk preferences by Pope and Chavas [Am J Agric Econ 76, 196–204 (1994)]. Production uncertainty is measured as the difference between actual admissions and admissions predicted by an autoregressive moving average model. Its effect on hospital cost is analyzed using a multilevel stochastic cost frontier model with random coefficients reflecting unobserved differences in technology. Public hospitals are found to opt for a higher probability of meeting unexpected demand, as predicted. Their operating cost is 1.1% higher than for private hospitals and even 1.9% higher than for teaching hospitals, creating an incentive to turn away patients or to keep them waiting for treatment.     

医保支付方式由后付制向预付制改革对供方医疗服务行为影响的机制和发展路径

全民医保制度下,支付方式提供了影响供方医疗服务行为的手段,成为调节卫生资源配置的重要杠杆。医保支付方式由后付制向预付制的改革,通过财务风险的转移调整对医疗机构和医生行为的激励,控制供方诱导需求行为带来的费用上涨,成为医疗保险制度改革的重要方向。但其发挥作用的基础是医疗服务提供方对支付方式的反应。医疗服务目标的多维性、医疗机构内部激励机制、管理者和医生的行为偏好都会影响改革的作用机制和强度。本文结合中国实际分析了后付制向预付制改革的作用机制和影响因素,并提出建立健康价值引导的支付方式,施行混合支付方式的策略,以及注重间接激励机制下医院管理者和医生参与的发展路径。     

Can Payers Use Prices to Improve Quality? Evidence from English Hospitals

In most activity‐based financing systems, payers set prices reactively based on historical averages of hospital reported costs. If hospitals respond to prices, payers might set prices proactively to affect the volume of particular treatments or clinical practice. We evaluate the effects of a unique initiative in England in which the price offered to hospitals for discharging patients on the same day as a particular procedure was increased by 24%, while the price for inpatient treatment remained unchanged. Using national hospital records for 205 784 patients admitted for the incentivised procedure and 838 369 patients admitted for a range of non‐incentivised procedures between 1 December 2007 and 31 March 2011, we consider whether this price change had the intended effect and/or produced unintended effects. We find that the price change led to an almost six percentage point increase in the daycase rate and an 11 percentage point increase in the planned daycase rate. Patients benefited from a lower proportion of procedures reverted to open surgery during a planned laparoscopic procedure and from a reduction in long stays. There was no evidence that readmission and death rates were affected. The results suggest that payers can set prices proactively to incentivise hospitals to improve quality. Copyright © 2014 John Wiley & Sons, Ltd.     

Measuring adverse selection in managed health care

Health plans paid by capitation have an incentive to distort the quality of services they offer to attract profitable and to deter unprofitable enrollees. We characterize plans' rationing as a "shadow price" on access to various areas of care and show how the profit maximizing shadow price depends on the dispersion in health costs, individuals' forecasts of their health costs, the correlation between use in different illness categories, and the risk adjustment system used for payment. These factors are combined in an empirically implementable index that can be used to identify the services that will be most distorted by selection incentives.     

Does price deregulation in a competitive hospital market damage quality?

Regulators may be hesitant to permit price competition in healthcare markets because of its potential to damage quality. We assess whether this fear is well founded by examining a reform that permitted Dutch health insurers to freely negotiate prices with hospitals. Unlike previous research on hospital competition that has relied on quality indicators for urgent treatments, we take advantage of a plausible absence of selection bias to identify the effect on the quality of elective procedures that should be more price responsive. Using data on all admissions for hip replacements to Dutch hospitals and a difference-in-differences comparison between more and less concentrated markets, we find no evidence that price deregulation in a competitive environment reduces quality measured by hip replacement readmission rates.     

The influence of bonus payments to doctors on hospital revenue: results of a quasi-experimental study

There is wide consensus that the ways in which providers are reimbursed by third parties will affect their behaviour and, hence, the efficient use of limited resources and the performance of health systems. However, there seems to be little evidence on how payment to hospital-based doctors affects hospital performance. This paper reports a case study conducted in China on the effects of different types of bonus payment to doctors, with a focus on how bonus payment might have affected hospital revenue growth. This has been an increasingly important goal of public hospitals as they have gained increased autonomy. A set of longitudinal quasi-experimental data, and a set of cross-sectional data, both derived from 108 public hospitals, were used for the analysis. It was found that, when a bonus system was introduced, and when the bonus model switched from one with a weaker incentive to provide services to one with a stronger incentive, there was a consistent sudden increase in the rate of growth of hospital revenue. Bonus type was also associated with the size of hospital service revenue. The results highlight the potential risks of linking remuneration too closely with revenue generation, and the need to ensure adequate attention to mechanisms of control and accountability when hospitals are given greater autonomy.     

A roadmap for comparing readmission policies with application to Denmark,England, Germany and the United States

Hospital readmissions receive increasing interest from policy makers because reducing unnecessary readmissions has the potential to simultaneously improve quality and save costs. This paper reviews readmission policies in Denmark, England, Germany and the United States (Medicare system). The suggested roadmap enables researchers and policy makers to systematically compare and analyse readmission policies. We find considerable differences across countries. In Germany, the readmission policy aims to avoid unintended consequences of the introduction of DRG-based payment; it focuses on readmissions of individual patients and hospitals receive only one DRG-based payment for both the initial and the re-admission. In Denmark, England and the US readmission policies aim at quality improvement and focus on readmission rates. In Denmark, readmission rates are publicly reported but payments are not adjusted in relation to readmissions. In England and the US, financial incentives penalise hospitals with readmission rates above a certain benchmark. In England, this benchmark is defined through local clinical review, while it is based on the risk-adjusted national average in the US. At present, not enough evidence exists to give recommendations on the optimal design of readmission policies. The roadmap can be a tool for systematically assessing how elements of other countries’ readmission policies can potentially be adopted to improve national policies.     

Upcoding in a National Health Service: the evidence from Portugal

For many years, evidence from the USA has pointed out to the existence of upcoding in management practices. Upcoding is defined as classifying patients in diagnosis‐related groups codes associated with larger payments. The incentive for upcoding is not restricted to private providers of care. Conceptually, any patient classification system that is used for payment purposes may be vulnerable to this sort of strategic behaviour by providers. We document here that upcoding occurs in a National Health Service where public hospitals have their payment (budget) tied to the classification of treatment episodes. Using diagnosis‐related groups data from Portugal, we found that the practice of upcoding has been used in the hospitals in a way leading to larger budgets (age of patients plays a key role). The effect is quantitatively small. Copyright © 2016 John Wiley & Sons, Ltd.     

Payment Mechanisms and the Composition of Physician Practices: Balancing Cost‐Containment,Access, and Quality of Care

We take explicit account of the way in which the supply of physicians and patients in the economy affects the design of physician remuneration schemes, highlighting the three‐way trade‐off between quality of care, access, and cost. Both physicians and patients are heterogeneous. Physicians choose both the number of patients and the quality of care to provide to their patients. When determining physician payment rates, the principal must ensure access to care for all patients. When physicians can adjust the number of patients seen, there is no incentive to over‐treat. In contrast, altruistic physicians always quality stint: they prefer to add an additional patient, rather than to increase the quality of service provided. A mixed payment mechanism does not increase the quality of service provided with respect to capitation. Offering a menu of compensation schemes may constitute a cost‐effective strategy for inducing physicians to choose a given overall caseload but may also generate difficulties with access to care for frail patients. Copyright © 2014 John Wiley & Sons, Ltd.