Money matters – primary care providers' perceptions of payment incentives

PurposePayments to healthcare providers create incentives that can influence provider behaviour. Research on unit-level incentives in primary care is, however, scarce. This paper examines how managers and salaried physicians at Swedish primary healthcare centres perceive that payment incentives directed towards the healthcare centre affect their work.Design/methodology/approachAn interview study was conducted with 24 respondents at 13 primary healthcare centres in two cities, located in regions with different payment systems. One had a mixed system comprised of fee-for-service and risk-adjusted capitation payments, and the other a mainly risk-adjusted capitation system.FindingsFindings suggested that both managers and salaried physicians were aware of and adapted to unit-level payment incentives, albeit the latter sometimes to a lesser extent. Respondents perceived fee-for-service payments to stimulate production of shorter visits, up-coding of visits and skimming of healthier patients. Results also suggested that differentiated rates for patient visits affected horizontal prioritisations between physician and nurse visits. Respondents perceived that risk-adjustments for diagnoses led to a focus on registering diagnosis codes, and to some extent, also up-coding of secondary diagnoses.Practical implicationsPolicymakers and responsible authorities need to design payment systems carefully, balancing different incentives and considering how and from where data used to calculate payments are retrieved, not relying too heavily on data supplied by providers.Originality/valueThis study contributes evidence on unit-level payment incentives in primary care, a scarcely researched topic, especially using qualitative methods.

Custom-made health-care: an experimental investigation

Background Physicians’ financial interests might conflict with the best service to patients. It is essential to gain a thorough understanding of the effect of remuneration systems on physician behaviour. Methods We conducted a controlled laboratory experiment using a within-subject design to investigate physician behaviour underpayment heterogeneity. Each physician provided medical care to patients whose treatments were paid for under fee-for-service (FFS) or capitation (CAP). Results We observed that physicians customized their care in response to the payment system. FFS patients received considerably more medical care than did CAP patients with the same illness and treatment preference. Physicians over-served FFS patients and under-served CAP patients. After a CAP payment reduction, we observed neither a quantity reduction under CAP nor a spillover in FFS patients’ treatment. Conclusions The results suggest that, in our experimental model, fee regulation can be used to some extent to control physician spending since we did not identify a behavioural response to the CAP payment cut. Physicians did not recoup lost income by altering treatment behaviour toward CAP and/or FFS patients. Experimental economics is an excellent tool for ensuring the welfare of all those involved in the health system. Further research should investigate payment incentives as a means of developing health care teams that are more efficient.

Do discontinuities in marginal reimbursement affect inpatient psychiatric care in Germany?

This paper examines the behaviour of mental health care providers in response to marginal payment incentives induced by a discontinuous per diem reimbursement schedule with varying tariff rates over the length of stay. The analyses use administrative data on 12,627 cases treated in 82 psychiatric hospitals and wards in Germany. We investigate whether substantial reductions in marginal reimbursement per inpatient day led to strategic discharge behaviour once a certain length of stay threshold is exceeded. The data do not show gaps and bunches at the duration of treatment when marginal reimbursement decreases. Using logistic regression models, we find that providers did not react to discontinuities in marginal reimbursement by significantly reducing inpatient length of stay around the threshold. These findings are robust in terms of different model specifications and subsamples. The results indicate that if regulators aim to set incentives to decrease LOS, this might not be achieved by cuts in reimbursement over LOS.

System Dynamics Modeling to Rethink Health System Reform

The Rethink Health Dynamics Model represents the complex dynamics of a regional health system in the United States and has been calibrated for more than 10 regions using nationwide and local data. When testing single interventions, the simulated improvement in system performance is often less than desired. By experimenting with combinations of interventions, the authors have identified recurring reasons for underperformance or intervention pitfalls. Here they discuss four common pitfalls and possible ways to overcome each with additional intervention. The pitfalls include (a) trying to cut costs without changing payment incentives; (b) depleting available funds without securing sustainable financing; (c) trying to achieve greater equity through service delivery without building capacity to meet greater demand; and (d) missing the opportunity to achieve multiple goals simultaneously through the use of mutually supporting interventions. The chapter illustrates each pitfall and proposed solution with causal feedback diagrams and simulation output graphs.

The Theory of Zariah Legal Movement and It's Application in Market Law in Indonesia

This paper explains the legal movement zariah legal theory of history, concepts, philosophies, ways of working and its implementation in developing legal issues. The legal issue taken is the issue of antitrust law in Indonesia, especially in the contestation of modern markets and traditional markets in Indonesia. This paper uses a qualitative method with secondary data retrieval which is analyzed with a normative approach, history and legislation. The results showed the law must be able to move (movement) to form the ideal law. In the ideal market law that is by protecting (sadd), empowering (fath) and also collaborating (jam'u). The form of protection (sadd), a small market can be done in accordance with the conditions and situations that develop in the market. The form of legal protection can be in the form of legal protection of existence, giving tax payment incentives, protection against price competition, protection through granting location and time permits, protection by differentiating types of products in each type of market, as well as cooperating between modern markets and markets traditional.

Valuing Carbon Stocks across a Tropical Lagoon after Accounting for Black and Inorganic Carbon: Bulk Density Proxies for monitoring

ABSTRACTManaging seagrass and mangrove can be enhanced through carbon valued payment incentives schemes. Success will depend on the accuracy and extent of the carbon stock mitigation and accessible methods of monitoring and marking changes. In a relatively closed socioecological Southeast Asian lagoon we estimated the value of total organic carbon stocks (TOC) of both seagrass and mangroves. Mitigation corrections were also made for black carbon (BC) and calcareous inorganic carbon equivalents (PICequiv), and their sediment dry bulk density (DBD) tested as a cost effective means of both estimating those stock concepts and possible impacts outside their parameter confidence intervals. Overall, seagrass and mangroves TOC densities across the lower lagoon ranged from 15.3±4.3 and 124.3±21.1 Mg C ha-1 respectively, 175.2±46.9 and 103.2±19.0 Mg C ha-1 for seagrass and 355.0±24.8 and 350.3±35.2 Mg C ha-1) for mangroves across the two upper lagoon branches. Only mangrove biomass made significant additional contributions ranging from 178.5±62.3 to 120.7±94.8 Mg C ha-1 for lower and upper regions respectively. The difference between the lagoons total seagrass and mangroves TOC stocks (5.98±0.69 and 390±33.22 GgC respectively) was further amplified by the lagoons’ larger mangrove area. When corrected for BC and PICequiv, the carbon stock mitigation was only reduced by a moderate 14.2%. Across the lagoon the sedimentary DBD showed strong (R2 = 0.85, P < 0.001) to moderate (R2 = 0.67, P < 0.001) linear correlations with seagrass and mangrove [TOC] respectively, moderate correlations with seagrass [PIC] (R2 = 0.6, P < 0.001), but an invariant and relatively constant response to mangrove [PIC] (2.7 kg m-3 ± 0.07). Valuations as CO2e was worth on average 0.44 million US$ y-1 over 20 years; less than the total income of the indigenous users as potential custodians (1.8 and 7.4 million US$ y-1). Implications of this valuation was discussed.