Exploring payment schemes used to promote integrated chronic care in Europe

doi:10.1016/j.healthpol.2013.07.007

Health Policy

Volume 113, Issue 3, December 2013, Pages 296-304

https://doi.org/10.1016/j.healthpol.2013.07.007 Get rights and content

Abstract

The rising burden of chronic conditions has led several European countries to reform healthcare payment schemes. This paper aimed to explore the adoption and success of payment schemes that promote integration of chronic care in European countries. A literature review was used to identify European countries that employed pay-for-coordination (PFC), pay-for-performance (PFP), and bundled payment schemes. Existing evidence from the literature was supplemented with fifteen interviews with chronic care experts in these countries to obtain detailed information regarding the payment schemes, facilitators and barriers to their implementation, and their perceived success.

Austria, France, England, the Netherlands, and Germany have implemented payment schemes that were specifically designed to promote the integration of chronic care. Prominent factors facilitating implementation included stakeholder cooperation, adequate financial incentives for stakeholders, and flexible task allocation among different care provider disciplines. Common barriers to implementation included misaligned incentives across stakeholders and gaming. The implemented payment schemes targeted different stakeholders (e.g. individual caregivers, multidisciplinary organizations of caregivers, regions, insurers) in different countries depending on the structure and financing of each health care system. All payment reforms appeared to have changed the structure of chronic care delivery. PFC, as it was implemented in Austria, France and Germany, was perceived to be the most successful in increasing collaboration within and across healthcare sectors, whereas PFP, as it was implemented in England and France, was perceived most successful in improving other indicators of the quality of the care process. Interviewees stated that the impact of the payment reforms on healthcare expenditures remained questionable.

The success of a payment scheme depends on the details of the specific implementation in a particular country, but a combination of the schemes may overcome the barriers of each individual scheme.

Introduction

Chronic conditions place a largely increasing economic burden on national healthcare budgets worldwide because of their rising incidence and prevalence [1]. Traditional healthcare payment schemes are designed for predominantly acute care settings and are therefore, restricted in their ability to tackle inefficiencies present in chronic care [2]. Tackling these inefficiencies could potentially reduce the increasing economic burden of chronic conditions [3].

Integrated chronic care refers to a “range of approaches deployed to increase coordination, cooperation, continuity, collaboration, and networking across different components of health service delivery” [4]. It puts the patient and his or her individual needs in the center and organizes care around the patient, thereby seeking to reduce redundancies and fragmentation in healthcare delivery [5]. Specifically, integrated chronic care aims to: (1) improve quality of care delivery, (2) ensure professional adherence to disease specific protocols and guidelines, (3) reduce unnecessary hospital utilization by strengthening the primary care sector, (4) share financial responsibility with other stakeholders, and in the long term, (5) contain the increasing chronic care expenditure [2].

Several countries have experimented with innovative approaches to achieve integration of chronic care [3]. Wagner's Chronic Care Model (CCM) is one of the most influential approaches and is based on the notion that productive interactions between stakeholders results in higher quality chronic care [6]. The CCM was used in many European countries to design and implement Disease Management Programs (DMPs) to achieve integration of chronic care [7]. DMPs are defined by the Disease Management Association of America as “a system of coordinated healthcare interventions and communications for populations with conditions in which patients self-care efforts are significant”. The success of DMPs is largely dependent on the financing context and payment mechanisms relevant to the various stakeholders involved, as they are not only influenced by their intrinsic motivation to provide good quality care but also by financial motives [8].

Payment schemes are key-factors in influencing stakeholder behavior, and can thus be used to stimulate their collaboration and steer healthcare delivery systems toward integration [5]. Therefore, several European countries have implemented different payment schemes in order to implement integrated healthcare delivery systems with regard to chronic care. However, there remains in the literature a lack of comprehensive information regarding which and how payment schemes have been implemented as well as about how the organizational structure, quality, and efficiency of chronic care was impacted as a result.

The aim of this paper is to provide an overview of payment schemes that have been implemented in Europe to promote integration of chronic care, highlight the facilitators and barriers to their implementation, and assess how stakeholders perceived their success.

Section snippets

Methods

A literature review was conducted to identify payment schemes introduced to improve the integration of chronic care in European countries since 1997. We searched in Google Scholar and Pubmed for relevant published papers using combinations of the following keywords: “chronic care”, “financing”, “payment”, “integrated”, “coordinated”, and “disease management”. The references of the resulting papers were then scanned to find additional publications relevant to our study. For our initial selection

Payment schemes for integrated chronic care

Traditional healthcare payment schemes include salary, capitation, and FFS [2]. They are not specifically designed to stimulate integrated care or improve the quality of chronic care [5], [11], [12].

Providing adequate financial incentives is a key instrument in achieving the implementation of integrated chronic care [5], as they influence stakeholder behavior [6], [12]. Several countries have implemented alternative payment schemes with financial incentives that overcome the limitations of

Results

From the literature review, five countries were identified as having implemented payment schemes to promote the integration of chronic care on a national level. These included Austria, England, France, Germany, and the Netherlands. Most payment schemes implemented in these countries were adaptations and a specific operationalization of the payment schemes described in the previous section. These adaptations were necessary because several of the payment schemes for integrated care were developed

Discussion

After providing an overview of payment schemes introduced in Austria, France, Germany, England, and the Netherlands, several discussion points come to light. First and foremost is that is some countries, the payment reforms were accompanied by financial arrangements targeting different stakeholders. PFC was introduced together with the financial pooling in Austria and the risk structure compensation in Germany, provided financial incentives and means to financial poolers and payers. On the

Conclusions

Payment schemes are valuable tools in stimulating the integration of chronic care delivery. The development of such payment schemes in Europe targeted those stakeholders who were expected to adjust their behavior, and provided them with adequate financial incentives. All payment reforms appeared to have changed the structure of chronic care delivery. PFC, as it was implemented in Austria, France and Germany, was perceived to be the most successful in increasing collaboration within and across

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¹: Both authors contributed equally to this work.

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Exploring payment schemes used to promote integrated chronic care in Europe

Abstract

Introduction

Section snippets

Methods

Payment schemes for integrated chronic care

Results

Discussion

Conclusions

Chronic Diseases and their common risk factors

Paying for chronic disease care

Tackling chronic disease in Europe: strategies, interventions and challenges

Managing chronic conditions: experience in eight countries

Improving the quality of healthcare for chronic conditions

Quality and Safety in Health Care

Improving chronic illness care: translating evidence into action

Health Affair

Dictionary of disease management terminology

Integrated Care: a position paper of the WHO European office for integrated healthcare services

International Journal of Integrated Care

Co-ordination and management of chronic conditions in Europe: the role of primary care – position paper of the European Forum for Primary Care

Quality in Primary Care

Caring for people with chronic conditions: a health systems perspective

Paying for quality: providers’ incentives for quality improvement

Health Affair

The provision of incentives in firms

Journal of Economic Literature

MMA Work Group to Advance Health Care Reform. Five payment models: the pros, the cons, the potential

Minnesota Medicine

Payment reform: analysis of models and performance measurement implications

Measurement of and reward for efficiency in California's pay-for-performance program

Health Affair

Increase the use of bundled payment approaches

Payment reform options: episode payment is a good place to start

Health Affair

Austrian health reform 2005: agreement reached

Austria health system review. Health systems in transition 2006

Developing and validating disease management evaluation methods for European healthcare systems; Final Report

Prevention of cardiovascular diseases: the role of primary care in Europe

EPA Cardio-Cardiovascular Prevention and Risk Management in Primary Care