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Linking Payment to Performance (Improved Health Outcomes)

Submitted by Paul Aliu | 08 Dec, 2015

With the rise of non-chronic diseases across the globe, it will be essential to establish a model that compensates healthcare providers based on improvement in health outcomes. This will be need to be based on agreed targets e.g. % of diabetic patients with adequately-controlled blood glucose or blood pressure (based on therapy or lifestyle modification), % reduction in infant/maternal deaths etc. Technology can also be employed – utilizing innovative health apps to better monitor patients remotely ensuring better treatment compliance or ‘just-in-time’ interventions as required.

For the betterment of individual and public health, healthcare providers will need to move from a payment system solely based on the number of interventions, number of assessments, treatments costs and healthcare professionals' time, to a model where the improvement of each patient's health contributes to the measure of healthcare delivery. This is a paradigm shift that will need to be driven by payors e.g. governments, insurance providers etc. Alternatively a portion of the fees/payments could also be linked to outcomes based on pre-defined conditions (depending on the local or national targets)

This will be a win-win situation as the patient benefits, the healthcare provider achieves meaningful results and the overall population health is improved resulting in a strategic partnership between the provider and the patient for success.


Bruce Landon Advisor Replied at 4:33 PM, 9 Dec 2015

There is much talk and excitement both nationally and internationally about reforming payment systems to focus on value rather than services provided. In the US, pay for performance systems have become commonplace, though most research to date has shown a relatively modest impact. Transitioning to a system that rewards improved outcomes is somewhat of a “holy grail”, as suggested in this post, holds substantial promise, but is also presents difficulties. For instance, just focusing on control of diabetes, there are many important decisions. What is the level of control desired (these guidelines have been in constant flux, particularly since the publication of the Accord trial)? How do we account for patient factors such as adherence to both medication and diet? What about SES factors that might influence control? Or the duration and severity of diabetes? Or number and types of medications required? Moreover, patients are much less interested in A1C control as an outcome and much more interested in hard outcomes such as heart attacks, kidney disease, or incidence of retinopathy. Thus, the trick in instituting such programs will be in the details and defining appropriate outcomes that are both measurable and fair will be the challenge.

Paul Aliu Replied at 5:45 AM, 10 Dec 2015

I do agree that detailing and defining the appropriate outcomes will be challenging. However, there are certain measures (either based on existing guidelines or clinical practice), which are widely accepted. Most importantly, each cluster, region, state or country will have to decide what their key health priorities are at any point in time. While I may have used diabetes as an example, in some areas it may be infectious diseases or cardiovascular diseases.

As an example, there is precedence in Scotland where a conscious decision was made about 15 years ago to make Heart Disease a clinical priority - the incidence of heart disease in Scotland was almost twice the national rate in the UK. This led to a redesign of the cardiology services with the active monitoring of new incidences of coronary heart disease and related mortality. This involved addressing various aspects including public education, lifestyle interventions, appropriate therapy, and an assessment of the role of various healthcare providers in achieving the desired outcomes.

For the overall improvement in the outcomes and numbers, individual healthcare providers all have a vital role to play - right from early lifestyle interventions, patient education through to appropriate prescribing and the subsequent monitoring. There should be adequate compensation for all interventions leading to improved outcomes, and in addition there should be an incentive to the healthcare provider once the agreed targets have been met.

In summary, each geographical 'unit' will have to first agree on their clinical priority, define the measures which are meaningful for them and agree on healthcare provider targets.

This Community is Archived.

This community is no longer active as of December 2018. Thanks to those who posted here and made this information available to others visiting the site.