Introduction
An outcome-based payment model is a payment model in healthcare in which the performance-related incentive payments for the healthcare providers depend for at least 10% on outcomes of the provided care, and which is designed to stimulate favourable effects in terms of quality of care or healthcare costs.
Methods
Inclusion and exclusion criteria
Search strategy
Selection procedure
Data extraction
-
name, country, and period in which the model was operating;
-
design features of the payment model;
-
effects on quality of care, healthcare utilization and healthcare costs.
Study appraisal
Results
Included studies
Name, country, period, and references | Healthcare purchaser | Targeted care | Targeted healthcare providers | Outcome indicators and their contribution (in %) to the performance-related payment size |
---|---|---|---|---|
Blue Cross Blue Shield (BCBS) Private; HMO | All care for BCBS insured | Integrated care model: all providers involved in targeted care | Cholesterol levels; HbA1c levels; blood pressure (35.3%)a | |
National Health Service (NHS) Public; single purchaser | Acute care, ambulance service, mental health care, and home care for NHS | Multiple provider model: all providers involved in targeted care | Unknown: differs locally (usually > 10%) | |
Centers for Medicare and Medicaid Services (CMS) Public | Hospital care for Medicare insured (= USA citizens of 65+ age) in 5 clinical areas: heart failure, pneumonia, hip/knee replacements, CABG, acute myocardial infarction | Single provider model: hospitals | 30-day mortality; readmission rate; post-ok haemorrhage; post-ok physiologic/metabolic derangement (16.4%)a | |
Centres for Medicare and Medicaid Services (CMS) Public | Hospital care for Medicare patients with acute myocardial infarction, heart failure and pneumonia | Single provider model: hospitals | 30-day hospital readmissions for acute myocardial infarction, heart failure, pneumonia, and hospital-acquired conditions (100%) | |
Hudson Health Plan, USA; since 2004 [34] | Hudson Health Plan Private; non-profit | Primary care for diabetes patients enrolled in Hudson Health Plan | Single provider model: primary care physicians | Hba1C levels; blood pressure; cholesterol levels; microalbumin levels (46.7%) |
Maryland Hospital-Acquired Condition Program (Maryland HACP), USA, since 2009 [35] | State of Maryland Public | Hospital care of all patients with hospital-acquired conditions (HACs) | Single provider model: hospitals | Hospital-acquired conditions (100%) |
Centres for Medicare and Medicaid Services (CMS) Public | All care for patients assigned to participating healthcare organisations | Integrated care model: all participating providers involved in targeted care | Blood pressure; HbA1C levels; cholesterol levels (18.2%) | |
Palo Alto Medical Foundation (PAMF) Private; non-profit | Primary care of all patients who visit targeted providers | Single provider model: primary care physicians | Blood pressure; HbA1C levels; cholesterol levels (20.0%) | |
Centres for Medicare and Medicaid Services (CMS) Public | All care for all patients assigned to participating healthcare organisations | Integrated care model: all participating providers involved in targeted care | Blood pressure; HbA1C levels; cholesterol levels (18.2%) | |
National Health Service (NHS) Public, single purchaser | All primary care for NHS insured (= all UK citizens) | Single provider model: primary care physicians | Blood pressure, HbA1C levels; cholesterol levels; lithium levels (20.8%) | |
Centres for Medicare and Medicaid Services (CMS) Public | Hospital care for CMS insured (= USA low income citizens or 65+ age) | Single provider model: hospitals | 30-day mortality, catheter associated urinary tract infections, central line-associated blood stream infections, surgical site infections, MRSA or C. Difficile infections and elective deliveries (2013: 0%; 2014: 25%; 2015: 30%; 2016: 50%; 2017: 50%) | |
National Health Insurance of Korea (NHIK) Public, single purchaser | Hospital care of NHIK insured (= all Korean citizens) in 3 clinical areas: Acute Myocardial Infarction (AMI), Caesar Sections, and acute stroke (since 2012) | Single provider model: hospitals | 30-day mortality (30%, AMI only) |
Indicators | Measurement | Payments | Refs. | |||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Type of indicators used | No. of indicators (of which outcome indicators) | Extra weight to outcome indicators | Net contribution of outcome indicators to quality score | Scores reported by | Risk-mitigating measures | Publication of scores | Feedback to providers | Incentive types | Requirements for bonus | Requirements for penalty | Requirements for shared savings | Maximum bonus/penalty size | ||
Narrow OBPMs | ||||||||||||||
CQUIN | S, P, O | Differs locally | Differs locally | Differs locally (29% average) | Providers | Risk-adjustment per indicator | ? | ? | P | n.a. | Differs locally | n.a. | − 0.5% (2009) to − 2.5% (2012) of contract income | |
HQID | S, P, O | AMI: 9 (1) CABG: 8 (3) HF: 4 (0) Pneu: 7 (0) H&K: 6 (3) | No | AMI: 11.1% CABG: 37.5% HF: 0% Pneu: 0% H&K: 50.0% | Providers | Case mix + exception reporting | Yes | Yes, annual | B, P | Top 20% overall; top 20% improvement | Bottom 20% | n.a. | B: + 2% on DRG P: − 2% on DRG | |
HRRP | O | 3(3) | n.a. | 100% | ? | Adjusted for age, sex, and co-morbidities | ? | ? | P | n.a. | Below 3-year average readmission rate | n.a. | 2012–2014: max − 1% p/DRG 2015+: max − 3% p/DRG | |
Hudson Health Plan | P, O | Diab: 14 (4) | $140/$300 per patient | 46.7% | Providers | ? | No | Yes, annual | B | None: fixed price per indicator per patient | n.a. | n.a. | $300,– per patient | [34] |
Maryland HACP | O | HACs: 49 (49) | No | 100% | Providers | Corrected for nr of HACs in Y-1 | ? | ? | B, P | ? | ? | n.a. | B: ? P: − 2% of total revenue | [35] |
PAMC P4P | S, P, O | 15 (3) | No | 20.0% | Health records | Case mix | Yes | Yes, quarterly | B | Achieving minimal target per indicator | n.a. | n.a. | $5000,– per year | |
QOF | S, P, O | ’04: 146 (10) ’06: 135 (?) ’14: 81 (17) | Yes | ’14: 20.8% | Providers | Exception reporting | Yes | Yes, annual | B | Achieving minimal target per indicator | n.a. | n.a. | + 25% of budget (after 2014: + 17%) | |
VBP | S, P, O | 2013: 12 (0) 2014–2015: 15 (3) 2016+: 17 (5) | No | 2013: 0% 2014: 25% 2015: 30% 2016: 50% 2017: 50% | Providers | Corrected for age, sex, CD | Yes | Yes | B, P | None: general + 1% (2013)/+ 2% (2017) per DRG | None: general − 1% (2013)/− 2% (2017) per DRG | n.a. | B: + 1% (2013)/2% (2017) P: − 1% (2013)/− 2% (2017) per DRG | |
VIP | P, O | AMI: 6 (1) CS: 1 (0) Stroke: 11 (0) | AMI: 1.8× | AMI: 30% CS: 0% Stroke: 0% | Claims data | Corrected for age | Yes | Yes, annual | B, P | Top 20% overall; top 20% improvement | Below threshold (= below 80% best score in Y-2) | n.a. | First phase: B: +1% on DRG P: − 1% on DRG Second phase B: + 1% on DRG P: − 1% on DRG | |
Broad OBPMs | ||||||||||||||
AQC | S, P, O | pc: 32 (5) sc: 33 (5) | pc: 3× sc: 3× | pc: 35.7% sc: 34.9% | Providers | Corrected for age, CD | ? | Yes, monthly | B, SS | > Median score; s-shaped relation | n.a. | None | B: + 10% of global budget for highest target SS: no max | |
MSSP | P, O | 33 (6) | No | 18.2% | Patients, providers | No downside risk (option); population correction | ? | ? | SS | n.a. | n.a. | Target on quality indicators | B: 60% of savings (50% if no downside risk) to 7.5% Medicare spending P: 10% of loss | |
Pioneer ACO | P, O | 33 (6) | No | 18.2% | Patients, providers | Lim downside risk; popul. correction | ? | ? | B, SS | ? | n.a. | Target on quality indicators | B: ? P: ? |
Effects of OBPMs
Model | Quality of care | Healthcare utilization/costs | Number of studies | Downs and Black score: mean (SD) |
---|---|---|---|---|
Narrow OBPMs | ||||
CQUIN | + | ? | 3 | 9.0 (1.0) |
HQID | Mixeda | − | 13 | 11.4 (1.6) |
HRRP | + | ? | 2 | 9.0 (1.0) |
Hudson Health Plan | Mixed | − | 2 | 13.0 (0) |
Maryland HACP | + | ? | 1 | 10.0 (0) |
PAMC P4P | − | ? | 2 | 10.5 (2.5) |
QOF | + | −b | 43 | 11.9 (1.9) |
VBP | − | ? | 9 | 11.5 (2.3) |
VIP | + | ? | 3 | 12.0 (2.0) |
Broad OBPMs | ||||
AQC | + | + | 10 | 12.4 (1.1) |
MSSP | + | + | 2 | 11.0 (0) |
Pioneer ACO | + | + | 2 | 11.0 (0) |