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Outcome-Based Payment Schemes: What Outcomes Do Patients with Cancer Value?

ABSTRACT: BACKGROUND:Uncertainty about the benefits new cancer medicines will deliver in clinical practice risks delaying patient access to new treatment options in countries such as England, where the cost effectiveness of new medicines affects reimbursement decisions. Outcome-based payment (OBP) schemes, whereby the price paid for the drug is linked to patients' real-world treatment outcome(s) has been put forward as a mechanism to accelerate access. Although OBP schemes have generally focused on clinical outcomes to determine reimbursement, the degree to which these represent the outcomes that are important to patients is unclear. OBJECTIVE:To advance the application of OBP we ask, what outcomes do patients with cancer value (most) that might form a practical basis for OBP? METHODS:A review of the literature on outcomes in cancer produced a long list of candidates. These were evaluated in a focus group with patients with cancer and were then, in a second focus group, distilled to a shortlist of ten outcomes using a card sort method. The ten outcomes were included in an online survey of patients with cancer and carers, who were asked to rank the importance of each outcome. RESULTS:The focus groups identified a range of both clinical and functional outcomes that are important to patients. Analyses of the 164 survey responses suggested that the four most important outcomes to patients and carers are survival; progression, relapse or recurrence; post-treatment side effects; and return to normal activities of daily life. CONCLUSION:Commissioners of cancer services wishing to instigate an OBP scheme should prioritise collecting data on these outcomes as they are important to patients. Of these, only mortality data are routinely collected within the national health service (NHS). Progression and some morbidity data exist but are not currently linked, creating a challenge for OBP.

SUBMITTER: Lorgelly P

PROVIDER: S-EPMC7478942 | biostudies-literature | 2020 Oct

REPOSITORIES: biostudies-literature

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Outcome-Based Payment Schemes: What Outcomes Do Patients with Cancer Value?

Lorgelly Paula P Pollard Jack J Cubi-Molla Patricia P Cole Amanda A Sim Duncan D Sussex Jon J

The patient 20201001 5

<h4>Background</h4>Uncertainty about the benefits new cancer medicines will deliver in clinical practice risks delaying patient access to new treatment options in countries such as England, where the cost effectiveness of new medicines affects reimbursement decisions. Outcome-based payment (OBP) schemes, whereby the price paid for the drug is linked to patients' real-world treatment outcome(s) has been put forward as a mechanism to accelerate access. Although OBP schemes have generally focused o ...[more]

PMID: 32676997

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Project description:Unlabelled?BackgroundCost is always a big issue for dialysis patients. In the present study, we analyzed the effect of different payment schemes on dialysis adequacy and clinical outcome in our peritoneal dialysis program. ?MethodsThis is a single-center cohort study. A total of 175 patients who began dialysis from January 2006 to December 2007 were included. Baseline data, including volume status, dietary intake and nutrition status, dialysis adequacy, and sodium removal were collected at 6 months after peritoneal dialysis. Based on the different payment schemes, the patients were divided into 2 groups, higher payment group (GHP, 130 cases, with more than 85% reimbursement), and lower payment group (GLP, 45 cases, with less than 50% payment or totally self-paid). Patients were followed up until dropout or until December 31, 2013. ?ResultsAt baseline, patients in the 2 groups had nearly the same residual renal function. But the GLP group patients dialyzed at a lower dose (4,516.91 ± 1,768.20 mL vs 6,058.17 ± 2,013.43 mL, p < 0.001). They had lower creatinine clearance (51.64 ± 24.23 L/w vs 70.54 ± 30.27 L/w, p < 0.001), sodium removal (2.23 ± 1.29 g vs 2.77 ± 1.29 g, p = 0.027), and fluid removal (970.33 ± 545.97 mL vs 1,146.66 ± 460.93 mL, p = 0.038). Normalized by height (in meters), the GLP group patients still had a lower normalized dialysis dose (2,890.61 ± 1084.44 mL/m vs 3,761.34 ± 1,237.10 mL/m, p < 0.001). Baseline nutritional and dietary parameters were comparable except that a lower daily protein intake (42.73 ± 10.99 g vs 47.26 ± 14.30 g, p = 0.032) and higher serum urea level (23.43 ± 6.88 mmol/L vs 19.84 ± 5.92 mmol/L, p < 0.001) were presented in the GLP group. There was no difference in volume status. During the follow-up, Kaplan-Meier analysis showed that there was no significant difference in patient survival and technique survival. In multivariate Cox regression analysis, after adjusting for related factors, payment was again not a strong predictor of survival in the study population. ?ConclusionOur study found that GLP group patients were adherent to lifestyle modification with lower dialysis doses, and they also had nearly the same long-term clinical outcome as the GHP group patients. Thus, lower dialysis doses combined with controlled dietary intake may be an effective approach to solve the dialysis problem for the low socio-economic status (SES) population.

Project description:Background:When risk adjustment is inadequate and incentives are weak, pay-for-performance programs, such as the Value-Based Payment Modifier (Value Modifier [VM]) implemented by the Centers for Medicare & Medicaid Services, may contribute to health care disparities without improving performance on average. Objective:To estimate the association between VM exposure and performance on quality and spending measures and to assess the effects of adjusting for additional patient characteristics on performance differences between practices serving higher-risk and those serving lower-risk patients. Design:Exploiting the phase-in of the VM on the basis of practice size, regression discontinuity analysis and 2014 Medicare claims were used to estimate differences in practice performance associated with exposure of practices with 100 or more clinicians to full VM incentives (bonuses and penalties) and exposure of practices with 10 or more clinicians to partial incentives (bonuses only). Analyses were repeated with 2015 claims to estimate performance differences associated with a second year of exposure above the threshold of 100 or more clinicians. Performance differences were assessed between practices serving higher- and those serving lower-risk patients after standard Medicare adjustments versus adjustment for additional patient characteristics. Setting:Fee-for-service Medicare. Patients:Random 20% sample of beneficiaries. Measurements:Hospitalization for ambulatory care-sensitive conditions, all-cause 30-day readmissions, Medicare spending, and mortality. Results:No statistically significant discontinuities were found at the threshold of 10 or more or 100 or more clinicians in the relationship between practice size and performance on quality or spending measures in either year. Adjustment for additional patient characteristics narrowed performance differences by 9.2% to 67.9% between practices in the highest and those in the lowest quartile of Medicaid patients and Hierarchical Condition Category scores. Limitation:Observational design and administrative data. Conclusion:The VM was not associated with differences in performance on program measures. Performance differences between practices serving higher- and those serving lower-risk patients were affected considerably by additional adjustments, suggesting a potential for Medicare's pay-for-performance programs to exacerbate health care disparities. Primary Funding Source:The Laura and John Arnold Foundation and National Institute on Aging.

Project description:ObjectivesCommunity-based health insurance (CBI) is a common mechanism to generate financial resources for health care in developing countries. We review for the first time provider payment methods used in CBI in developing countries and their impact on CBI performance.MethodsWe conducted a systematic review of the literature on provider payment methods used by CBI in developing countries published up to January 2010.ResultsInformation on provider payment was available for a total of 32 CBI schemes in 34 reviewed publications: 17 schemes in South Asia, 10 in sub-Saharan Africa, 4 in East Asia and 1 in Latin America. Various types of provider payment were applied by the CBI schemes: 17 used fee-for-service, 12 used salaries, 9 applied a coverage ceiling, 7 used capitation and 6 applied a co-insurance. The evidence suggests that provider payment impacts CBI performance through provider participation and support for CBI, population enrolment and patient satisfaction with CBI, quantity and quality of services provided and provider and patient retention. Lack of provider participation in designing and choosing a CBI payment method can lead to reduced provider support for the scheme.ConclusionCBI schemes in developing countries have used a wide range of provider payment methods. The existing evidence suggests that payment methods are a key determinant of CBI performance and sustainability, but the strength of this evidence is limited since it is largely based on observational studies rather than on trials or on quasi-experimental research. According to the evidence, provider payment can affect provider participation, satisfaction and retention in CBI; the quantity and quality of services provided to CBI patients; patient demand of CBI services; and population enrollment, risk pooling and financial sustainability of CBI. CBI schemes should carefully consider how their current payment methods influence their performance, how changes in the methods could improve performance, and how such effects could be assessed with scientific rigour to increase the strength of evidence on this topic.

Project description:BackgroundMixed payment schemes have become one of the effective measures to balance medical costs and quality of medical services. However, altruism as an intrinsic motivation may influence the effect of switching from a pure payment system to mixed payment schemes. This study aimed to quantify physicians' altruism and analyze the effect of changes of payment system on physicians' altruism and thus proposed references for the reform of payment system.MethodsWe simulated an exogenous payment system in a controlled laboratory with five experimental groups and 150 medical student subjects. Physicians' altruism was measured by estimating altruistic parameter and marginal rate of substitution. The non-parametric test and the least square regression analysis were used to analyze the differences of altruistic parameters between pure payment systems and mixed payment schemes. Finally, we analyzed the effect of changes in payment system accompanied by changes in trade-off range on physicians' altruism.ResultsWe find that the mean value of individual altruistic parameter is 0.78 and the marginal rate of substitution is 1.078. Their estimates at the individual level were significantly positively correlated (Spearman's ρ = 0.715, p < 0.01). The shift from pure payment system to mixed payment scheme reduced the altruistic parameter. However, the altruistic parameter increased with the increase of the trade-off range. Physicians who were more altruistic generated higher patients' health benefit. For each unit increase in altruistic parameter, the increase in patients' health benefit was lower in mixed payment scheme than in the pure payment system.ConclusionThe estimates of altruistic parameters are reliable. Physicians attach a higher weight to patients' benefit than to their own profit. Mixed payment schemes improve physicians' behavior and relate to lower altruistic parameters; physicians only need to sacrifice less personal profits to generate the same or even higher altruistic parameter as under the pure payment system. The design of mixed payment schemes that make the interests of physicians and patients close to each other by reducing the trade-off range can provide implication for the reform of payment system in which the physicians' interest and the patients' benefit are consistent.

Project description:ObjectiveTo examine the impact of a scaled implementation of workforce training intervention on value-based payment measures in a large home-based Medicaid managed long-term care plan population in New York.Data sourcesManaged long-term care clients' health assessments from the Uniform Assessment System of New York merged with paid claims, home health aide operational visit data, and workforce training rosters between 2018 and early-2020.Study designA quasi-experimental design was used. Exposure and control groups were constructed using the proportion of service hours delivered by trained aides between clients' baseline and follow-up/outcome assessments. Multivariate logistic generalized linear and additive models were estimated to examine associations between exposure to trained aides and value-based payment measures.Data collection/extraction methodsThe analytic sample consisted of 19,212 pairs of assessments from 13,320 long-term care clients continuously enrolled in the plan between baseline and follow-up/outcome assessments. Matched assessment pairs were 6-10 months apart.Principal findingsOver 27% of the study population (n = 3656 clients) received services from one or more of 8683 trained aides. Statistically significant associations were observed for four of seven value-based payment measures; however, the presence and magnitudes of positive training effects differed by client service needs. With covariate adjustment, workforce training had the largest estimated positive impacts on rates of flu vaccination among average-need clients (1.60%, standard error [SE] = 0.01), not experiencing uncontrolled pain among above-average-need clients (0.69%, SE = 0.001), stable/improved pain intensity among heavy-need clients (1.25%, SE = 0.01), and stable/improved shortness of breath among light-need clients (0.88%, SE = 0.003).ConclusionAlthough we found mixed associations between scaled workforce training implementation and value-based payment metrics, we noted workforce training could benefit high-need long-term care recipients. Health indicators more sensitive to the daily support provided by direct care workers should be integrated into value-based health care models.

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Outcome-Based Payment Schemes: What Outcomes Do Patients with Cancer Value?

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Outcome-Based Payment Schemes: What Outcomes Do Patients with Cancer Value?

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