Healthcare financing

Healthcare financing

Possibility # 1 Fee for service

In the fee for service approach, healthcare providers such as doctors and hospitals get paid for the type, quantity / volume and complexity of the care they deliver. http://www.strategy-business.com/media/file/sb64_11305.pdf https://hbr.org/2016/07/how-to-pay-for-health-care

A problem with the fee for service approach is that it does not reward the quality or efficiency of medical care.

If you incentivize volume, you get a lot of visits, a lot of procedures, a lot of activity. What you do not get are things that are not counted in volume, for example care coordination and helping people to stay healthy. https://hbr.org/2016/07/how-to-pay-for-health-care http://youtu.be/33gs0kDfle0 http://www.strategy-business.com/media/file/sb64_11305.pdf

Possibility # 2 Capitation

In the capitation approach, the insurer makes a single payment for each patient per month to a single delivery organization.

In other words, contrary to the fee for service model, the insurer does not pay various providers for each service delivered. https://hbr.org/2016/07/how-to-pay-for-health-care

The capitation approach rewards providers for lowering the overall cost of treating the population without tying the outcomes back to individual patients or providers.

Examples:  Limiting the use of expensive tests and drugs.  Reducing readmissions.  Shortening lengths of stay.  Discharging patients to their homes rather than to higher-cost rehabilitation facilities. https://hbr.org/2016/07/how-to-pay-for-health-care

A problem with the capitation model is that just as with the fee for service model, the wrong incentives are created because the volume of services - and not value for patients is rewarded / reimbursed / paid for.

https://hbr.org/2016/07/how-to-pay-for-health-care

Another problem with the capitated approach is that it encourages or requires patients and their referring doctors to use in-house providers – even if outside providers get better results for treating the patient’s particular condition. Why? Because in the capitated approach, outside services reduces net revenue and results in underutilization of existing internal capacity.

Capitation thereby eliminates patient choice, limits competition and entrenches large existing systems. https://hbr.org/2016/07/how-to-pay-for-health-care

Possibility # 3 Diagnosis related groups

Under the diagnosis related groups payment model, abbreviated DRG, a single payment is made for a set of services provided at a given location.

https://hbr.org/2016/07/how-to-pay-for-health-care

A problem with the diagnosis related groups approach is that many support services, which are important to achieve good outcomes and overall value, are not covered.

Examples: Systematic follow-up and patient education.

Also, healthcare providers have no incentive to innovate to improve patient outcomes. https://hbr.org/2016/07/how-to-pay-for-health-care

Another problem with the diagnosis related groups payment model is that the payment does not cover the full care cycle for treating the patient’s condition.

By continuing to make separate payments to each specialist physician, hospital, and post-acute care site involved in a patient’s care, the diagnosis related groups payment model perpetuates a system of uncoordinated care. https://hbr.org/2016/07/how-to-pay-for-health-care

In der Schweiz Behandlungen werden innerhalb von 1 Spital erfasst. Pauschalen werden nicht nach der Diagnose festgelegt, sondern erst beim Spitalaustritt, das heisst nach Abschluss der Behandlung im Spital.

Problem: Ein Anreiz zum unnötig häufigen Operieren in einem Spital entsteht.

In den Niederlanden Eine Pauschale deckt sämtliche Behandlungen bis zur vollständigen Genesung der Patienten ab. Wie eine Fallpauschale verteilt wird, aushandeln Spitäler, Reha- und Pflegeinstitutionen und Hausärzte untereinander. Die Patienten werden vom CaseManager, vom Hausarzt oder vom Spezialisten von der Diagnose bis zur Genesung begleitet. Der Staat reguliert zentral und unabhängig. Ihm gehören keine Spitäler.

Vorteil: Spitäler, Reha- und Pflegeinstitutionen und Hausärzte haben ein finanzielles Interesse daran, dass Patienten möglichst bald gesund werden. https://www.beobachter.ch/leben-gesundheit/medizin-krankheit/artikel/spitaeler_fallpauschalen-mit-nebenwirkungen

Possibility # 4 Bundled payments

Bundled payments are a direct and intuitive way to pay clinical teams for delivering value, condition by condition.

They put accountability on outcomes that matter to patients. https://hbr.org/2016/07/how-to-pay-for-health-care

With bundled payments, a single price is set for all the care required to treat a patient’s particular medical condition.

https://hbr.org/2016/07/how-to-pay-for-health-care

People can choose the providers that best meet their particular needs. Example: Diagnostic tests from one provider and surgical services from another.

The healthcare providers, that people choose, are the ones that work most effectively in improving outcomes for patients. https://hbr.org/2016/07/how-to-pay-for-health-care

With bundled payments, providers with overall responsibility for the full care cycle for a condition will be empowered and motivated to coordinate and integrate all the specialists and facilities involved in care.

For example, hospital-based healthcare professionals stay involved in care after patients have left the hospital. https://hbr.org/2016/07/how-to-pay-for-health-care

Bundled payments work well for chronic conditions because of the huge benefits that result from coordinated longitudinal care by a multidisciplinary team.

https://hbr.org/2016/07/how-to-pay-for-health-care

A problem with the bundled payments approach is that it can be difficult for specialists to work with each other.

https://hbr.org/2016/07/how-to-pay-for-health-care

Possibility # 5 Payment when people are healthy

Doctors and hospitals are paid for helping people stay healthy.

http://faculty.chicagobooth.edu/richard.thaler/research/pdf/Overcoming%20Obstacles%20to%20Better%20Health%20Care.pdf

In China, some doctors are paid monthly when you are healthy.

If you are sick, you don’t pay that month.

http://www.youtube.com/watch?v=q1zh49J5rsg