Module 9: Outcome-Based Payment Models Flashcards
Quality of care consists of structure, process, and outcomes. What are those?
- Structure (inputs): people, materials, policy, information, technology
- Process (activities): how the inputs are used
- Outcomes (outputs): results achieved from activities employing inputs
What are 3 major health care payment models?
- Fee-for-service:
- Paid for goods and services provided. - Salary:
- Paid for the time providing goods and services. - Capitation:
- Paid for number of people enrolled to receive goods and services.
What is fee-for-service?
Common method of payment for most health professionals not directly employed by health care organizations, including community pharmacies.
- Incentive to provide more goods and services
Most community pharmacies use what kind of payment model? Why?
- Most community pharmacies use a “buy-and-bill” FFS model with medications purchased from suppliers and dispensed to patients on-demand.
- Emphasis on quantity over quality. - Increasingly, pharmacies are wanting to provide new clinical services to better meet the needs of their patients, and to diversify their revenues.
What is the pro and con of fee-for-service in pharmacy?
- New clinical services (also using the FFS model) are seen to positively affect patient outcomes with:
- Increased access to vaccinations, improved adherences, and safe medication use - However, pharmacies are incentivized to prioritize dispensing over other clinical services.
- Increasing pressure to maintain dispensing revenues causes pharmacies to fill more scripts with fewer staff.
- As a result, clinical services with the potential to improve patient outcomes tend to fall away or delivered on a less consistent basis.
What is salary?
Most common method of remuneration for those employed by organizations within Canada’s health care system, including pharmacists.
- No financial Incentive to provide goods and services
How does salary fit into pharmacy?
Existing outside the globally-funded public-funded health care system, community pharmacy revenues derived for FFS activities carried out by salaried employees.
- Owners incentivized to produce more goods and services vs. goals of professional staff
- Misalignment of incentives with potential for conflict
What is capitation?
Set dollar amount for each person enrolled/eligible to receive goods and services (patient rolls).
- Surpluses retained by the provider of goods and services
Where in health care is capitation seen mostly?
Often used with primary care physicians to encourage more preventive care to reduce demand for more expensive secondary and tertiary care.
- Incentivized to reduce the number/cost of services
When in pharmacy are we maybe seeing capitation?
Beginning to see examples in community pharmacy (e.g. the Membership Pharmacy Model)
- Contract with employer-group to provide prescriptions at cost plus a recurring membership fee to provide services to improve patient outcomes
What is a big con of FFS, salary, and capitation?
FFS, salary and capitation can affect provider behaviour of even the most ethical health care professional in a manner that does not optimize patient outcomes.
What are value-based payment models? (2)
- Also referred to as performance-based or pay-for-performance (P4P) models, the intent is to create an incentive to improve patient outcomes while maintaining or decreasing the relative cost of care.
- To add value to goods and services. - Providers are paid for achieving “outcomes” associated with the goods and services provided
- Those meeting or exceeding performance targets are rewarded financially (Direct).
- Those failing to meet targets see a decrease in remuneration (Indirect).
Are P4P models being used in pharmacy?
- Slower to emerge in community pharmacy compared to other health care settings.
- Traditionally, the model of payment for pharmacy services was, and for many, continues to be fee-for-service. - Over the past decade, P4P for pharmacy services has increased significantly in the United States and Europe.
Results of P4P in pharmacies has been mixed. Why?
- P4P models are attractive to payers and have seen some success; but the overall evidence suggests little change in quality, cost savings, or clinical outcomes.
- Outcome measures are often complex due to multiple stakeholders
What are the cons of P4P in pharmacies? (4)
Creates incentives to focus resources on those metrics being tracked for payment.
1. Practitioner gaming to maximize revenue.
2. Punishes pharmacies that may be producing positive outcomes for other patients
3. Can add to health disparities if incentives are for conditions that fail to address the needs of underserved populations.
Additional Concerns:
4. Often fail to reward high performers.
Go through the GSC Value-Based Pharmacy program they tried to come out with - Years 1-3
Planned roll out over 3 years:
Year 1: Send out score cards to pharmacies and encourage them to enroll (for a fee) in a system that would provide pharmacy-specific reports to identify “high needs” patients.
Year 2 (2018): Pharmacy scorecards to be made available to plan clients and plan members*
Year 3 (2019): Tie reimbursement to scores.
- Reward high performers and “incentivize” poor performers to provide higher quality care.
GCS P4P had a Patient-Impact Scorecard with 8 metrics. What were they?
– 3 metrics tracking adherence rates
– 3 track chronic disease management
– 1 on enrollment in a GSC CV Coaching program
– 1 measuring high-risk medication use
What concerns did CPhA have with the GCS Model? (6)
- No compelling evidence P4P initiatives improve outcomes or reduce costs.
- Some metrics outside control of pharmacists, and these are weighed more heavily.
- Targets fail to account for regional differences.
- Software to identify patients linked to rating must be purchased by the pharmacy.
- Not all GSC pharmacies can qualify for rating and may cause some patients to unfairly switch pharmacies.
- Due to peer comparison, no guarantee of higher reimbursement with improved metrics.
