Effects of Results-Based Financing on Patient Satisfaction in Afghanistan

<p>A Results-Based Financing (RBF) program has been implemented in Afghanistan since September 2010 to improve the quality of health care and increase the utilization of maternal and child health services. This PhD study examines the impact of RBF on patient satisfaction and on determinants of patient satisfaction at health facility level in Afghanistan. Determinants of patient satisfaction in the study refer to health provider performance, availability of medicines, vaccines, equipment, and physical appearance of health facilities. I used data collected from a panel of health facilities over a three-year period. The data consist of nearly 3000 patient observations and exit interviews. I included 112 health facilities in my study. These health facilities were part of the 428 health facilities which had been randomly assigned to treatment and control groups prior to the start of RBF in 2010. Financial incentives were distributed among health providers in the treatment facilities through four administration mechanisms: salary-based, task-based, equal-amount, and mixed-method. Follow-up surveys were conducted in 2011 and 2012 in the same 112 facilities, but for new cross-sections of patients and health providers. I analysed a range of patient satisfaction and patient satisfaction determinants measures using a regression-adjusted difference-in-differences estimation model. The results from this study show that after a period of two years, there was an increase of only 8 percentage points in the proportion of patients who were very satisfied with services as a whole. However, the effect was not statistically significant. Similarly, specific aspects of patient satisfaction were not significantly affected by the intervention. Likewise, RBF did not have any significant effect on health provider performance, on availability of medicines, vaccines, and equipment, and on physical appearance of health facilities over a two-year period. I also found no difference in RBF treatment effects by the different incentive administration mechanisms. My study provides evidence which suggests that paying monetary incentives alone may not have the impetus to improve health provider performance to the satisfaction of patients in a post conflict country. In such settings, RBF initiatives need to include both financial and non-financial incentives for health providers in order to achieve the intended objectives of quality of care and patient satisfaction. My study provides pragmatic recommendations aimed at holistic approaches to improving quality and delivery of healthcare in a post conflict setting.</p>

Effects of Results-Based Financing on Patient Satisfaction in Afghanistan

<p>A Results-Based Financing (RBF) program has been implemented in Afghanistan since September 2010 to improve the quality of health care and increase the utilization of maternal and child health services. This PhD study examines the impact of RBF on patient satisfaction and on determinants of patient satisfaction at health facility level in Afghanistan. Determinants of patient satisfaction in the study refer to health provider performance, availability of medicines, vaccines, equipment, and physical appearance of health facilities. I used data collected from a panel of health facilities over a three-year period. The data consist of nearly 3000 patient observations and exit interviews. I included 112 health facilities in my study. These health facilities were part of the 428 health facilities which had been randomly assigned to treatment and control groups prior to the start of RBF in 2010. Financial incentives were distributed among health providers in the treatment facilities through four administration mechanisms: salary-based, task-based, equal-amount, and mixed-method. Follow-up surveys were conducted in 2011 and 2012 in the same 112 facilities, but for new cross-sections of patients and health providers. I analysed a range of patient satisfaction and patient satisfaction determinants measures using a regression-adjusted difference-in-differences estimation model. The results from this study show that after a period of two years, there was an increase of only 8 percentage points in the proportion of patients who were very satisfied with services as a whole. However, the effect was not statistically significant. Similarly, specific aspects of patient satisfaction were not significantly affected by the intervention. Likewise, RBF did not have any significant effect on health provider performance, on availability of medicines, vaccines, and equipment, and on physical appearance of health facilities over a two-year period. I also found no difference in RBF treatment effects by the different incentive administration mechanisms. My study provides evidence which suggests that paying monetary incentives alone may not have the impetus to improve health provider performance to the satisfaction of patients in a post conflict country. In such settings, RBF initiatives need to include both financial and non-financial incentives for health providers in order to achieve the intended objectives of quality of care and patient satisfaction. My study provides pragmatic recommendations aimed at holistic approaches to improving quality and delivery of healthcare in a post conflict setting.</p>

Reliability of claims-based measures used to assess cancer care quality.

42 Background: As value-based payment models for cancer care expand, the need for measures which reliably assess the quality of care provided increases. This is especially true for models like the Oncology Care Model (OCM) that rely on quality rankings to determine potential shared savings. Under models like these, unreliable measures may result in arbitrary application of value-based payments. The goal of this project is to evaluate the extent to which measures used within the OCM are reliable indicators of provider performance. Methods: Data for this project came from North Carolina Medicare claims from 2015-2017. Episodes were attributed to physician practices at the tax identification number (TIN) level, lasted 6 months, and were divided into two performance years beginning 1/1/2016 and 7/1/2016. TINs with fewer than 20 attributed patients were excluded. Three claims-based OCM measures were used in this evaluation: 1) proportion of episodes with all-cause hospital admissions; 2) proportion of episodes with all-cause emergency department (ED) visits or observation stays; and 3) proportion of patients that died who were admitted to hospice for 3 days or more. Risk adjustment followed the method described by measure specifications from the OCM. Reliability was calculated as the ratio of between practice variation (e.g. signal) to the sum of between practice variation and within practice variation (e.g. noise). Variance estimates were derived from hierarchical logistic regression models used for risk adjustment. Results: For the hospitalization and ED visit measures, episode counts for years 1 and 2 were 30,746 and 28,430 and TIN counts were 86 and 84, respectively. Hospice use measures had fewer episodes (2,677 and 2,428) and TINs (36 and 33). Across all measures, median reliability scores failed to achieve the recommended 0.7 threshold and only hospice had a median reliability score above 0.5 (Table). Conclusions: These findings suggest claims-based measures included in the OCM may produce imprecise estimates of provider performance and are vulnerable to random variation. Consideration should be given to developing alternative measures which may be more reliable estimates of provider performance and to increasing minimum denominator requirements for existing measures.[Table: see text]

Long Live Marketization for Local Public Spaces: A Study of Scandinavian Managers’ Satisfaction with Private Provider Performance

Continued critiques, evidence and newer reform trends have increasingly contested the use of market-centered models–the competition prescription–for urban public space maintenance as well as other local services. This article adopts a contextualized contingency perspective on the competition prescription and questions the contested status of market-centered models in a survey-based study of the current use of and satisfaction with private providers for maintenance of parks/greenspaces and road/streets in Scandinavian local governments. The study finds widespread use of and satisfaction with private providers. However, satisfaction depends on national context and multiple contingencies. The study challenges the contested status of market-centered models, highlights that different models serve different strategic objectives, and directs attention to discussions of context and key contingencies that define how well market-centered models perform.

Modeling Medicare’s Oncology Care Model bundles at more clinically granular levels: Evaluating the impact on provider performance.

e18854 Background: Aggregating different subtypes of cancers into bundles is an important methodology in oncology payment reform as an alternative to fee for service. However, expected resource utilization can vary significantly across cancer subtypes. We evaluated the impact that modeling Chronic Leukemia into a more clinically granular two part framework of chronic myelogenous leukemia (CML) and chronic lymphocytic leukemia would have on OCM results and the risk that the distribution of clinical subtypes at a practice would influence overall performance in the bundle. Methods: OCM episodes of chronic leukemia initiating between July 2016 and June 2019 were subdivided on the basis of individual ICD-10 coded diagnoses on cancer-related E&M visits. From a total of 4,658 episodes, we randomly sampled with replacement 3,500 episodes from 16 practices using empirical data distributions. Data models and mappings were developed based on clinical knowledge and exploratory data analyses to subdivide the OCM bundle of Chronic Leukemias into CLL and CML. Total cost of care and episode target prices were calculated through implementation of the OCM methodology. The distributional consistencies of episode target, cost, cost above target, and percent above target for the two diseases were evaluated by two-sample Kolmogorov-Smirnov (KS) tests. Results: The CML and CLL subtypes modeled from the aggregate OCM bundle demonstrated significantly different cost distributions relative to each other. As anticipated, treatments used in each subtype varied significantly marking different patterns of expected resource utilization. In our model, CLL episodes were on average 13.7% over target. Average CLL episode costs were $52.2K vs. an average target of $47.6K with 54% of episodes running over target. In contrast, CML episodes were 6.1% under target. Average CML episode costs were $45.2K vs. an average target of $50.3K with 43% of episodes running over target. Conclusions: Value based payment models in oncology such as OCM can be improved by modeling cancer bundles in more clinically granular ways that better reflect expected resource utilization for appropriate, standard of care. Insufficient clinical granularity in bundle construction can lead to provider performance being influenced by the distribution of patient subtypes at the practice. This can lead to inappropriate shifts of risk from payers to providers in value based models. Aggregate vs. subtype episode costs (mean, 5th, and 95th percentiles).[Table: see text]

Impact of network effects on service provider performance in digital business platforms

PurposeDigital business platforms (DBPs) such as Alibaba and Google Shopping are partnership networks that use the Internet to bring service providers (e.g. retail vendors) and customers together. One of the benefits of DBPs is network effects, in which customers can purchase from multiple providers, giving rise to a unique network. However, few studies have explored which service providers benefit from network effects and which do not.Design/methodology/approachUsing the theories of transaction costs and network analysis, the authors apply network models to DBPs to understand which service providers benefit from network effects.FindingsThe authors identify three segments of service providers: (1) those with high prominence (connection to providers with high network centrality), (2) those with high network constraint (adjacent to isolated providers) and (3) those with low prominence and constraint. The authors find that segments (1) and (3) benefit from reciprocated customer exchanges, and thus benefit from network effects, while high constraint segment (2) providers do not benefit from reciprocated exchanges. Moreover, the authors find that for segments (2) and (3) future sales have a negative association with unreciprocated customer exchanges, while segment (1) has no significant association between unreciprocated exchanges and future sales.Research limitations/implicationsThe authors discuss implications for a multisided platform (MSP), as it decides which service providers to attract, promote and recommend. They can use this study’s results to know which segments of providers will increase network effects to make the platform more valuable.Practical implicationsThis paper provides managers of service platforms with strategies for managing relations with their service providers.Social implicationsService platforms are an important and disruptive business model. The authors need to understand how network effects operate to create efficient platforms.Originality/valueThis paper extends the literature on MSPs by quantifying network effects and showing not all service providers benefit equally on an MSP from network effects. Critical insights into network effects on the MSP are provided, including different ways it can impact provider sales.