19. Suggesting an outcome based reimbursement model adjusted to the context of rheumatology
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Editor's Notes
This project has just been initiated and is just about to start. SLL will decide in two weeks. Today, breifly outline our assumptions, goals and ways in which we intend to dealing with this task.I will however, leave loots of room for discussion as we are amateurs and are grateful for any comments. Hence, the plan is incomplete. Further, the My My name is, and the other participants are: Staffan, SLL, Sofia etc. THecurrent version focuses on the practical task of designing a new reimbursement system. This process raises a lot of theoretical research questions, of philosophical nature.
Today’s systems are fragmented but current structures have not been good at ’solving’ the problem of fragmentation in health care. Providers are encouraged to improve isolated tasks rather than the overal lprocess. That is doing things better rather than doing the right things. Current systems pay attention to the quantity rather than quality of care. Hence, care providers are not rewarded for e.g. keeping their patients well and reducing the number of times the patients need to visit their doctor.Sofia can explain this with some examples. This is remarkable! There is something fundamentally wrong with this system.
Of course we’re not the first one to ask what we can do about this, and the potential of reimbursement systems. My impression of the literature is that alot of work has been done, but many projects confuse performance with process. Pay for Performance in the US mostly measure process aspects such as adherence to guidelines, patient safety etc. There are outcomes based models but the studies are poorly designed (often no controls) and reviews conclude that it is difficult to make any conclusions about the effectiveness of various designs. Hence, the literature, from what I’ve read, does not tell us how to design an outcomes based reimbursemnt model let alone the impact it could have in practice. Having said that, the literature does make us aware of anumber of issues that we need to consider.
Previous work highlights many issues we need to consider. However, few articles discuss the extent to which new reimbursement systems really encourage continuous organizational innovation. How we can create systems (institutionalize) that encourage the people in healthcare to critically evaluate current processes, asking themselves, could we make patients better by collaborating with e.g. primary care in new ways?
VBT provides a clear answer to the question: what is the purpose, the design, the basis and the recipient of the reward? Straightforward model telling us what to do. However, we need to adjust it to our context.
According to porter, the defitiion of value implicitly suggests that the amount of value possible to produce is not fixed but can be continously improved. Further, outcomes should not be monetized. He is pro diagnosis specific outcomes measures. Partly as outcomes measurement is primarily, a tool for learning and improvement.
Tier1: mortality, degree of health/recovery (e.g. functional and pain level achieved, degreeof independenc, ability to return to work, satisfaction with outcome) Tier 2: Time to recovery (or return to normal activities(to betw attainable activities) and disutility of care (e.g. pain, infection rate, length of hostipal stay.Cycel time. Tier 3: Sustailability of health status achieved (time to reccurence, seriousness of recurrences (ongoing pain status, ) negative long-term consequences of theorapy (eg complications, loss of mobility due to to inadequate reahab). Outcome measures should be selectedbased on thei relevance from patient perspective and medical knowledge.The improatnce of each tier will vary across patients. This model is useful as it encourages us to think about complementarities and tradeoffs between outcomes. For example, faster cycle times often means improved sustainability of health. From our view, it is important to revise the outcomes along with the develoment of medical knowledge.
Regression analysis and stratigying patient groups based on the major risk factors such as stageofdisease, typeof diseas,patient prerequisites. Christensen (2009) outlines differentprocesses based on the risk involved. Value shops where providers have to engage in pattern recognition based on experience and intuition, or can simply follow the odds but not guarantee outcomes. Such processesshould only be regulated in terms of their inputs. (by the people they employ). Risk factors need to be revised.
As far as I understand, ABC estimates the cost of resources actually used by activities inproducing services. Italso exploses unused capacity.traditional accounting systems focus on the availability of purahcesd rresources.
Reimbursement should be aligned with the unit of value. Flexibility as regards process. Process measures can be used, but primarily for internal purposes. Outcome measurement is esential to measure success ad minimize incentives to limitvalue-ehnacning services
In the first cycle, care providers should be rewardedfor reducing the disease activity as soon as possible. There are complementarities here, short cycle times influence long-term outcomes (and costs).
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