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Editor's Notes

• #31: Integration of care requires integration of payment. When discussion payment systems it is always useful to make a distinction between the base payment system and supplementary payment to stimulate improvements in outcomes or cost saving on top of that. This slide shows different base payment schemes. Many countries have base payment schemes on the left. Each system has pros and cons. But they all lack specific incentives to stimulate multidisciplinary collaboration and improve outcomes. Therefore, an increasing number of countries is moving towards more integrated payment systems and apply P4P systems on top of them to mitigate the perverse incentives of the different payment systems. In this graph I have placed a number of dominant payment schemes on, depending on the level in integration in payment (on the vertical axis) and the level of integration in care in care (on the horizontal axis). As care becomes more integrated, payment also needs to become more integrated. Most of the traditional schemes to pay single organisations. like fee for service…, lack incentives to stimulate multidisciplinary collaboration and improve outcomes. For example a hospital that is paid by DRGs has an incentive to produce a lot of DRGs and at the same time an incentive to free the hospital bed quickly, once a patient is hospitalized. It has not incentive to substitute care from the hospital to the primary care. When care becomes more integrated, for example by creating multidisciplinary networks of collaborating caregivers from different organisations, different payment systems emerge like the bundled payment system in the Netherlands. Full organisational integration may require budget based on characteristics of the residents like with population-based payment. . Perverse incentives can be mitigated by: Combining methods with opposing incentives Complement dominant payments with financial incentives for quality and/or cost control We see an increase of different blended payment systems in which P4P incentives are put on top of the dominant payment system. Van Herck et al concluded in their 2010 review of P4P that P4P has on average led to a 5% improvement in performance. However there is much variation and more recent P4P initiatives like the alternative quality contract report much greater improvements.
• #34: We have studied these innovative payments for integrated care in Europe and grouped this into 3 categories…