Tag Archives: P4P

How we pay our Doctors

2 Mar

Before the health insurances era Doctors were often payed in nature with eggs, chicken or other farm products. Needless to say that they were often poorly paid, furthermore people called them so lately that the care was unable to keep them alive and the doctors lost their patients in the same time. Once the Doctors and the people they cared got the health insurances to be created Doctors received currencies for their services and could see more than once their patients. The issue of payment was transferred to the insurer. In the beginning insurers reimbursed with a fee for service model like the patients did previously. But the increasing amount of money needed made them think of an alternative payment model. And here came the Pay for Performance model.

France has already put in place such a payment model here:
http://www.csmf.org/upload/File/Conv_med/conv_med_annexes_110726.pdf

USA will implement this mode of payment in 2019 here:
http://www.medpagetoday.com/PublicHealthPolicy/Medicare/40568

Developing countries have already experienced these kind of payment here:
http://www.esciencecentral.org/journals/impact-of-pay-for-performance-on-utilization-of-health-services-and-quality-of-care-in-low-and-middle-income-countries.hccr.1000116.pdf

Below are other links related to the way Doctors will be payed in the future:

http://theincidentaleconomist.com/wordpress/can-the-better-care-lower-cost-act-live-up-to-its-name/

http://advocacyblog.acponline.org/2013/07/house-sgr-bill-promotes-medical-homes.html?utm_source=twitterfeed&utm_medium=twitter&utm_campaign=Feed:+AcpAdvocateBlog

http://advocacyblog.acponline.org/2013/04/does-measurement-improve-performance.html

http://doctorscaucus.gingrey.house.gov/news/documentsingle.aspx?DocumentID=364922

http://energycommerce.house.gov/markup/markup-committee-print-amend-title-xviii-social-security-act-reform-sustainable-growth-rate

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Le quotidien du médecin

10 Jan

Today is a celebration day. One of the most read daily medical news-paper in France, especially by general practitioners, has just quoted, in its January 9th, 2012 issue, the Health Services Authors blog.


The author of a letter published by the Quotidien du Médecin, Dr Olivier Guilhot, a general practitioner giving primary cares in a disadvantaged suburb of Marseilles, made a reference to two posts of the Health Services Authors blog: this one and this one.
I’m very pleased that this blog could be used as a material in an interesting debate about the risk of moral hazard attached to the declarative side of the financial incentives attribution procedure in the brand new P4P implemented in France last summer. This is the mission statement of health services authors blog to participate and fuel all the discussions in the health services policy provided that they are grounded on sound research results. If I do not endorse the entire contents of the letter nevertheless I was sensitive to some very stylish excerpts like for example the evocation of the ghosts of fathers of the social security system in 1945 (now all dead), victorious of the Nazis, inheriting the solidarity spirit from the concentration camps, assisting to an actual meeting and standing up and leaving the assembly when hearing a health care provider saying that it’s just sufficient to declare you succeeded the objectives to receive the financial incentive. I know the great majority of my colleagues are not that greedy. But here we touch the critical point: the moral hazard like insurers say.

Performance Measurement

19 Dec
English: California OPA Health Care Quality Re...

Image via Wikipedia

Converting Practice Guidelines Into Quality Measure

Performance incentives have been recently adopted in France by the national health care insurer to remunerate French Doctors. In Health care, when one can not measure outcomes one measures process. But a good process for an individual patient doesn’t reflect necessarily a good process for the average patient studied by the evidence-based medical research. In a precedent post I presented what the heterogeneity of treatment effect means. In the present post I will try to highlight where stands the fundamental difference between professional guidelines and quality assessment tools of physician practice. Guidelines stem from the average patient. A quality assessment tool assesses the individual patient dealing with the heterogeneity or deviation around the mean value. From now on, given the use of guidelines made by health policy makers to evaluate health care professionals, it becomes a priority goal for searchers to take into account this use when writing their guidelines. For that purpose they should more insist on the heterogeneity of their results and perform sub group analysis across the different risk level of disease to which their studied subjects are exposed. They should accurately determine if their recommendations are applicable to subjects with multiple co morbidities. That is only at this condition that guideline will coincide with a sound balanced quality assessment tool for physician practice.

The thoughts here above were inspired to me by the reading of the two following interesting papers authored by physicians working for the Department Veterans Affairs which manage the most important health care system in the United States:

Garber AM. Evidence-Based Guidelines As a Foundation For Performance Incentives. Health Affairs. 2005 Jan;24(1):174-179. Available from: http://dx.doi.org/10.1377/hlthaff.24.1.174.

Walter LC, Davidowitz NP, Heineken PA, Covinsky KE. Pitfalls of Converting Practice Guidelines Into Quality Measures. JAMA: The Journal of the American Medical Association. 2004 May;291(20):2466-2470. Available from:http://dx.doi.org/10.1001/jama.291.20.2466.

P4P for French primary care physicians for the first time of their history

26 Jul

For the first time of their history, French primary care practitioners will be paid for performance. Until now their remuneration was only of “fee for service” type. But the new contract with social security scheme of July 2011 introduces a dose of “pay for performance”. Goals that will have to be reached in order to receive bonuses will be fixed by the contract negotiated with the French national social security scheme.

Old time when practitioners only had an obligation of mean is from now on a past history. Bonuses are now also paid for the obtaining of results.

The risk of such a new remuneration is that it only add on to the previous one “fee for service” remuneration without address the problem of repetitive un-necessary medical cares.

Pay for performance should potentially show better results in a salaried context like in England than in a fee for service context like it is in France.

Furthermore patients with multiple chronic diseases often do not correspond to any guidelines available.  But… wait and see.

All the more, results depend on how generous will be the financial incentive and how high will be set the performance thresholds. From now on bonuses costs are estimated between 360 and 380 million Euros.

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