Search

Background: The implementation of different reimbursement methods has various positive and negative effects on the health system of different countries. Identifying the challenges of these methods is essential to improve these reimbursement methods and modify them if required. This article aimed to qualitatively assess the challenges of current hospitals' payment systems in the Iranian health system and determine the required solutions for modifying these payment systems. Methods: This qualitative study was conducted in 2019. Semi-structured interviews were conducted recruiting 20 experts including operational, middle and top managers working in three different levels of health systems. Data collection was continued until it reached a saturation point. MAXQDA 10 was used for data analysis. The data content analysis method was used to analyze the data and the themes and categories were determined. Results: The challenges of the payment systems were categorized into four main themes regarding policy, cost, regulatory and functional challenges, and 15 sub-themes. The findings related to the proposed strategies were presented in six main themes consisting of legal solutions, structural reform, cost, quality improvement, service provider and client, and monitoring and evaluation; and 12 sub-themes. Conclusion: This study showed that the health systems in Iran face various structural and procedural challenges in terms of reimbursement mechanisms. Therefore, it is recommended that policymakers pay attention to these challenges before making any changes. Using hybrid payment systems can be one of the proper solutions.

Provider payment methods are a key health policy lever because they influence healthcare provider behaviour and affect health system objectives, such as efficiency, equity, financial protection and quality. Previous research focused on analysing individual provider payment methods in isolation, or on the actions of individual purchasers. However, purchasers typically use a mix of provider payment methods to pay healthcare providers and most health systems are fragmented with multiple purchasers. From a health provider perspective, these different payments are experienced as multiple funding flows which together send a complex set of signals about where they should focus their effort. In this article, we argue that there is a need to expand the analysis of provider payment methods to include an analysis of the interactions of multiple funding flows and the combined effect of their incentives on the provision of healthcare services. The purpose of the article is to highlight the importance of multiple funding flows to health facilities and present a conceptual framework to guide their analysis. The framework hypothesizes that when healthcare providers receive multiple funding flows, they may find certain funding flows more favourable than others based on how these funding flows compare to each other on a range of attributes. This creates a set of incentives, and consequently, healthcare providers may alter their behaviour in three ways: resource shifting, service shifting and cost shifting. We describe these behaviours and how they may affect health system objectives. Our analysis underlines the need to align the incentives generated by multiple funding flows. To achieve this, we propose three policy strategies that relate to the governance of healthcare purchasing: reducing the fragmentation of health financing arrangements to decrease the number of multiple purchaser arrangements and funding flows; harmonizing signals from multiple funding flows; and constraining providers from responding to undesirable incentives. [ABSTRACT FROM AUTHOR]

Health insurance was prioritized as one of the four key areas for reform in China's Health Care Reform Plan released in April 2009. The Plan aimed to expand coverage, enhance security, and improve payment methods, but implementation was sluggish. In 2011, the government announced that social health insurance (SHI) schemes had reached a coverage rate of 95%, but official statistics did not match the claim. Universal coverage is still an unfinished mission, while inadequate financing and benefit design remain major challenges. Despite a substantial increase in government funding over the past decade, SHI schemes have so far never accounted for more than 54% of national health care expenditure. Surplus has also become a serious policy issue for SIH funds. Finally, payment methods still require further reform and improvement. Traditional fee-for-service payments prevail in many localities, and new payment methods, such as capitation, global budgets, diagnosis-related groups (DRGs), per diem payments, and mixed payments, are only in the stage of experimentation. The health care delivery system still lacks sufficient governance structure and incentives. Health insurance reform is an important part of welfare-state building, and China still has a long path ahead before it reaches its goals in this respect. [ABSTRACT FROM AUTHOR]

The various mechanisms of payment for health services aim to create incentives which affect the health provider behavior, economic efficiency and productivity of a health system, and ultimately its quality. This paper describes and analyzes the current methods of funding used in hospital systems worldwide, from the "diagnosis related groups" (DRGs) method to the recent development of hospital-based "pay for performance" (P4P) of the US Medicare system and the "payment by results" of the UK. Emphasis is placed on studies measuring hospital efficiency before and after adoption of the new methods of payment. The necessary institutional reforms are described which enhance competition between the health care funding schemes, such as social security funds and insurance companies, and the health care providers, such as hospitals. The Greek case is evaluated from the beginning of the economic crisis in 2009 until the present, with the establishment of a single health insurance fund, EOPXY, the creation of the database esy.net for the collection of complete, reliable data on the costing and operation of the state hospitals (ESY) in order to monitor their financial and administrative functioning, and the adoption of the payment method of KENDRGs, where classification was made in 760 groups based on the initial diagnosis and treatment process. Finally, several changes are proposed which would lead towards a more sophisticated payment system based on performance criteria, including quality. [ABSTRACT FROM AUTHOR]

Abstract: While there is broad agreement that the way that health care providers are paid affects their performance, the empirical literature on the impacts of provider payment reforms is surprisingly thin. During the 1990s and early 2000s, many European and Central Asian (ECA) countries shifted from paying hospitals through historical budgets to fee-for-service (FFS) or patient-based payment (PBP) methods (mostly variants of diagnosis-related groups, or DRGs). Using panel data on 28 countries over the period 1990–2004, we exploit the phased shift from historical budgets to explore aggregate impacts on hospital throughput, national health spending, and mortality from causes amenable to medical care. We use a regression version of difference-in-differences (DID) and two variants that relax the DID parallel trends assumption. We find that FFS and PBP both increased national health spending, including private (i.e. out-of-pocket) spending. However, they had different effects on inpatient admissions (FFS increased them; PBP had no effect), and average length of stay (FFS had no effect; PBP reduced it). Of the two methods, only PBP appears to have had any beneficial effect on “amenable mortality”, but we found significant impacts for only a couple of causes of death, and not in all model specifications. [Copyright &y& Elsevier]

Background: In an attempt to achieve universal health coverage, Nigeria introduced a number of health insurance schemes. One of them, the Formal Sector Social Health Insurance Programme (FSSHIP), was launched in 2005 to provide health cover to federal government and formal private sector employees. It operates with two levels of purchasers, the National Health Insurance Scheme (NHIS) and health maintenance organisations (HMOs). This study critically assesses purchasing arrangements between NHIS, HMOs and healthcare providers and determines how the arrangements function from a strategic purchasing perspective within the FSSHIP., Methods: A qualitative study undertaken in Enugu state, Nigeria, data were gathered through reviews of documents, 17 in-depth interviews (IDIs) with NHIS, HMOs and healthcare providers and two focus group discussions (FGDs) with FSSHIP enrolees. A strategic purchasing lens was used to guide data analysis., Results: The purchasing function was not being used strategically to influence provider behaviour and improve efficiency and quality in healthcare service delivery. For the purchaser-provider relationship, these actions are: accreditation of healthcare providers; monitoring of HMOs and healthcare providers and use of appropriate provider payment mechanisms for healthcare services at every level. The government lacks resources and political will to perform their stewardship role while provider dissatisfaction with payments and reimbursements adversely affected service provision to enrolled members. Underlying this inability to purchase, health services strategically is the two-tiered purchasing mechanism wherein NHIS is not adequately exercising its stewardship role to monitor and guide HMOs to fulfil their roles and responsibilities as purchasing administrators., Conclusions: Purchasing under the FSSHIP is more passive than strategic. Governance framework requires strengthening and clarity for optimal implementation so as to ensure that both levels of purchasers undertake strategic purchasing actions. Additional strengthening of NHIS is needed for it to have capacity to play its stewardship role in the FSSHIP., Competing Interests: Competing interests: None declared.

Background: Provider payment mechanisms (PPMs) create incentives or signals that influence the behaviour of health care providers. Understanding the characteristics of PPMs that influence health care providers' behaviour is essential for aligning PPM reforms for improving access, quality, and efficiency of health care services. We reviewed empirical literature that examined the characteristics of PPMs that influence the behaviour of health care providers., Methods: We systematically searched for empirical literature in PubMed, Web of Science, and Google Scholar databases and complemented these with physical searching of the references of selected papers for further relevant studies. A total of 16 studies that met our inclusion and exclusion criteria were identified. We analysed data using thematic review., Results: We identified seven major characteristics of PPMs that influence health care providers' behaviour. Of these characteristics, payment rate, the sufficiency of payment rate to cover the cost of services, timeliness of payment, payment schedule, performance requirements, and accountability mechanisms were the most important., Conclusions: Our review found that health care providers' behaviour is influenced by the characteristics of PPMs. Provider payment mechanism reforms that optimally structure these characteristics can elicit required incentives for access, equity, quality, and efficiency in service delivery among health care providers towards achieving universal health coverage., (© 2018 The Authors The International Journal of Health Planning and Management Published by John Wiley & Sons Ltd.)