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Financial risk allocation and provider incentives in hospital-insurer contracts in The Netherlands.

ABSTRACT: In healthcare systems with a purchaser-provider split, contracts are an important tool to define the conditions for the provision of healthcare services. Financial risk allocation can be used in contracts as a mechanism to influence provider behavior and stimulate providers to provide efficient and high-quality care. In this paper, we provide new insights into financial risk allocation between insurers and hospitals in a changing contracting environment. We used unique nationwide data from 901 hospital-insurer contracts in The Netherlands over the years 2013, 2016, and 2018. Based on descriptive and regression analyses, we find that hospitals were exposed to more financial risk over time, although this increase was somewhat counteracted by an increasing use of risk-mitigating measures between 2016 and 2018. It is likely that this trend was heavily influenced by national cost control agreements. In addition, alternative payment models to incentivize value-based health care were rarely used and thus seemingly of lower priority, despite national policies being explicitly directed at this goal. Finally, our analysis shows that hospital and insurer market power were both negatively associated with financial risk for hospitals. This effect becomes stronger if both hospital and insurer have strong market power, which in this case may indicate a greater need to reduce (financial) uncertainties and to create more cooperative relationships.

SUBMITTER: Gajadien CS

PROVIDER: S-EPMC9002227 | biostudies-literature | 2022 Apr

REPOSITORIES: biostudies-literature

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Financial risk allocation and provider incentives in hospital-insurer contracts in The Netherlands.

Gajadien Chandeni S CS Dohmen Peter J G PJG Eijkenaar Frank F Schut Frederik T FT van Raaij Erik M EM Heijink Richard R

The European journal of health economics : HEPAC : health economics in prevention and care 20220412 1

In healthcare systems with a purchaser-provider split, contracts are an important tool to define the conditions for the provision of healthcare services. Financial risk allocation can be used in contracts as a mechanism to influence provider behavior and stimulate providers to provide efficient and high-quality care. In this paper, we provide new insights into financial risk allocation between insurers and hospitals in a changing contracting environment. We used unique nationwide data from 901 h ...[more]

PMID: 35412163

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Project description:BackgroundFrequent retesting for HIV among persons at increased risk of HIV infection is critical to early HIV diagnosis of persons and delivery of combination HIV prevention services. There are few evidence-based interventions for promoting frequent retesting for HIV. We sought to determine the effectiveness of financial incentives and deposit contracts in promoting quarterly HIV retesting among adults at increased risk of HIV.Methods and findingsIn peri-urban Ugandan communities from October to December 2018, we randomized HIV-negative adults with self-reported risk to 1 of 3 strategies to promote HIV retesting: (1) no incentive; (2) cash incentives (US$7) for retesting at 3 and 6 months (total US$14); or (3) deposit contracts: participants could voluntarily deposit US$6 at baseline and at 3 months that would be returned with interest (total US$7) upon retesting at 3 and 6 months (total US$14) or lost if participants failed to retest. The primary outcome was retesting for HIV at both 3 and 6 months. Of 1,482 persons screened for study eligibility following community-based recruitment, 524 participants were randomized to either no incentive (N = 180), incentives (N = 172), or deposit contracts (N = 172): median age was 25 years (IQR: 22 to 30), 44% were women, and median weekly income was US$13.60 (IQR: US$8.16 to US$21.76). Among participants randomized to deposit contracts, 24/172 (14%) made a baseline deposit, and 2/172 (1%) made a 3-month deposit. In intent-to-treat analyses, HIV retesting at both 3 and 6 months was significantly higher in the incentive arm (89/172 [52%]) than either the control arm (33/180 [18%], odds ratio (OR) 4.8, 95% CI: 3.0 to 7.7, p < 0.001) or the deposit contract arm (28/172 [16%], OR 5.5, 95% CI: 3.3 to 9.1, p < 0.001). Among those in the deposit contract arm who made a baseline deposit, 20/24 (83%) retested at 3 months; 11/24 (46%) retested at both 3 and 6 months. Among 282 participants who retested for HIV during the trial, three (1%; 95%CI: 0.2 to 3%) seroconverted: one in the incentive group and two in the control group. Study limitations include measurement of retesting at the clinic where baseline enrollment occurred, only offering clinic-based (rather than community-based) HIV retesting and lack of measurement of retesting after completion of the trial to evaluate sustained retesting behavior.ConclusionsOffering financial incentives to high-risk adults in Uganda resulted in significantly higher HIV retesting. Deposit contracts had low uptake and overall did not increase retesting. As part of efforts to increase early diagnosis of HIV among high-risk populations, strategic use of incentives to promote retesting should receive greater consideration by HIV programs.Trial registrationclinicaltrials.gov: NCT02890459.

Project description:Importance:The strongest evidence for the effectiveness of Medicare's Hospital Readmissions Reduction Program (HRRP) involves greater reductions in readmissions for hospitals receiving penalties compared with those not receiving penalties. However, the HRRP penalty is an imperfect measure of hospitals' marginal incentive to avoid a readmission for HRRP-targeted diagnoses. Objectives:To assess the association between hospitals' condition-specific incentives and readmission performance and to examine the responsiveness of hospitals to condition-specific incentives compared with aggregate penalty amounts. Design, Setting, and Participants:This retrospective cohort analysis used Medicare readmissions data from 2823 US short-term acute care hospitals participating in HRRP to compare 3-year (fiscal years 2016-2019) follow-up readmission performance according to tertiles of hospitals' baseline (2016) marginal incentives for each of 5 HRRP-targeted conditions (acute myocardial infarction, heart failure, chronic obstructive pulmonary disease, pneumonia, and hip and/or knee surgery). Main Outcomes and Measures:Linear regression models were used to estimate mean change in follow-up readmission performance, measured using the excess readmissions ratio, with baseline condition-specific incentives and aggregate penalty amounts. Results:Of 2823 hospitals that participated in the HRRP from baseline to follow-up, 2280 (81%) had more than 1 excess readmission for 1 or more applicable condition and 543 (19%) did not have any excess readmissions. The mean (SD) financial incentive to reduce readmissions for incentivized hospitals ranged from $8762 ($3699) to $58 158 ($26 198) per 1 avoided readmission. Hospitals with greater incentives for readmission avoidance had greater decreases in readmissions compared with hospitals with smaller incentives (45% greater for pneumonia, 172% greater for acute myocardial infarction, 40% greater for hip and/or knee surgery, 32% greater for chronic obstructive pulmonary disease, and 13% greater for heart failure), whereas hospitals with no incentives had increases in excess readmissions of 4% to 7% (median, 4% [percentage change for nonincentivized hospitals was 3.7% for pneumonia, 4.2% for acute myocardial infarction, 7.1% for hip and/or knee surgery, 3.7% for chronic obstructive pulmonary disease, and 3.7% for heart failure]; P < .001). During the study period, each additional $5000 in the incentive amount was associated with a 0.6- to 1.3-percentage point decrease, or up to a 26% decrease, in excess readmissions (P < .001). Regression to the mean explained approximately one-third of the results depending on the condition examined. Conclusions and Relevance:The findings suggest that improvements in readmission avoidance are more strongly associated with incentives from the HRRP than with aggregate penalty amounts, suggesting that the program has elicited sizeable changes. Worsened performance among hospitals with small or no incentives may indicate the need for reconsideration of the program's lack of financial rewards for high-performing hospitals.

Project description:BackgroundIn 2012, the Ministry of Health in British Columbia, Canada, introduced a $75 incentive payment that could be claimed by hospital physicians each time they produced a written post-discharge care plan for a complex patient at the time of hospital discharge.ObjectiveTo examine whether physician financial payments incentivizing enhanced discharge planning reduce subsequent unplanned hospital readmissions.DesignInterrupted time series analysis of population-based hospitalization data.ParticipantsIndividuals with one or more eligible hospitalizations occurring in British Columbia between 2007 and 2017.Main measuresThe proportion of index hospital discharges with subsequent unplanned hospital readmission within 30 days, as measured each month of the 11-year study interval. We used interrupted time series analysis to determine if readmission risk changed after introduction of the incentive payment policy.Key resultsA total of 40,588 unplanned hospital readmissions occurred among 409,289 eligible index hospitalizations (crude 30-day readmission risk, 9.92%). Policy introduction was not associated with a significant step change (0.393%; 95CI, - 0.190 to 0.975%; p = 0.182) or change-in-trend (p = 0.317) in monthly readmission risk. Policy introduction was associated with significantly fewer prescription fills for potentially inappropriate medications among older patients, but no improvement in prescription fills for beta-blockers after cardiovascular hospitalization and no change in 30-day mortality. Incentive payment uptake was incomplete, rising from 6.4 to 23.5% of eligible hospitalizations between the first and last year of the post-policy interval.ConclusionThe introduction of a physician incentive payment was not associated with meaningful changes in hospital readmission rate, perhaps in part because of incomplete uptake by physicians. Policymakers should consider these results when designing similar interventions elsewhere.Trial registrationClinicalTrials.gov ID, NCT03256734.

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Financial risk allocation and provider incentives in hospital-insurer contracts in The Netherlands.

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Financial risk allocation and provider incentives in hospital-insurer contracts in The Netherlands.

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