Expert answer:This week, assigned Presenters should post a PowerPoint presentation with detailed notes section that contains the following:Incorporation and analysis of the Learning Resources from this 2-week unit, including identification of any apparent gaps in the literatureAn original research topic related to the week’s literature (the proposed research topic can be related to the general topic for the week or to gaps in the literature for the week, or it can be related to a specific reading for the week)Background information on the research topic, including identification of principal schools of thought, tendencies in the academic literature, or commonalities that define the academic scholarship regarding your topicEvaluation of the main concepts with a focus on their application to business/management practice and their impact on positive social changeA minimum of 10 peer-reviewed, scholarly new referencesNote: The presentation must be in APA format and must incorporate direct evidence of addressing the Learning Objectives from this 2-week unit. Each of the content slides must include detailed notes/paragraphs with appropriate citation of peer-reviewed, scholarly references.Note: The 10 peer reviewed references should be listed in the sample annotated bibliography template ALSO.I attached 3 pdf files to be used in the presentation in addition to the 10 peer reviewed references.Kindly use the APA presentation template (attached).I should receive (presentation file and annotated bibliography document).
how_bundled_health_care.pdf
how_to_reform_payment.pdf
policy_options_to_contain_healthcare_costs.pdf
apa_presentation_template.ppt
sample_annotated_bibliography_6_16_16__5_.doc
Unformatted Attachment Preview
HEALTH
How Bundled Health Care
Payments Are Working in
the Netherlands
by Jeroen N. Struijs
OCTOBER 12, 2015
The system for paying health care providers is
extremely fragmented. In response, both the United
States and the Netherlands are now experimenting
with bundled-payment models, whereby a single
prospective payment is made for all services for a
patient with a given condition, even when multiple
providers deliver that care. I believe that the ongoing
Dutch experience with bundled payments has unique
lessons for U.S. policymakers.
Bundled-payment efforts in both countries shift
accountability to a single provider-led entity that
must ensure quality, thereby emphasizing value over
volume of care. The U.S. Centers for Medicare and
Medicaid Services’ Comprehensive Care for Joint
Replacement (CCJR) program, for example, uses a
mandatory bundled payment for total-hip and totalknee replacement surgeries. In 2007, the Netherlands
initiated a bundled-payment model for type 2
diabetes care and, subsequently, for chronic
obstructive pulmonary disease and vascular-risk
management. (A similar model for pregnancy and
childbirth is underway.)
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2
The orientations of the U.S. and Dutch models differ somewhat. The CCJR model has a downstream
focus: improving care during inpatient stays and the 90-day post-discharge period, to limit the need
for hospital readmissions. The Dutch model, by contrast, has an upstream focus: improving primary
care to prevent expensive outpatient-specialist care and hospitalizations. I will describe how the
Dutch bundled-payment model for diabetes care works, as well as its successes and challenges.
Dutch bundles
In our model in the Netherlands, insurers pay a bundled payment to a principal contracting entity —
the care group — to cover a full range of diabetes-care services for a fixed period of 365 days. The care
group, a new legal entity in the Dutch health care system, comprises multiple providers, often
exclusively general practitioners. By signing the bundled-payment contract, the care group assumes
both clinical and financial accountability for all diabetes patients assigned to its care program. The
contract is limited to general diabetes care (services to manage the underlying disease and reduce risk
for complications) and does not include services to address complex complications that may arise.
Therefore, the model focuses on primary care.
General decisions about services covered in the diabetes-care bundle were made at a national level
and, in 2007, codified in a Health Care Standard for type 2 diabetes. For the various components of
diabetes care, the care group either delivers services or subcontracts with other providers. Insurers
and care groups negotiate the price of the bundle, and the care group negotiates with the
subcontracted care providers about fees for specific services. All services are covered under the basic
benefit package for all Dutch citizens. The Dutch bundled-payment model is consistent with the
principles of Michael E. Porter and Thomas H. Lee’s strategic value agenda for health care.
Keys to success
In the four years since the Dutch bundled-payment model for type 2 diabetes was introduced, patient
mortality rates and costs have dropped significantly. (My colleagues and I expect to report the
specific numbers in a journal article in the next few months.) The model has had success for three key
reasons:
1. It was codified. The Dutch Diabetes Federation Health Care Standard (DFHCS), agreed on by all
national provider and patient associations, specifies the minimum requirements for optimal
diabetes care and sets the criteria for improvements. By law, the bundled-payment contract must
include all services described in the DFHCS, which identifies what services to provide but not who
delivers those services or where and how they are delivered. In addition, the DFHCS specifies a
standardized minimum data set of quality measures, thereby giving care groups an incentive to
adopt innovations and to reallocate tasks so that providers each do the work that best matches
their qualifications.
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2. It fostered transparency through use of electronic health records. By 2010, three years after bundled
payments were introduced, 66% of the care groups had web-based electronic health records
(EHRs) where subcontracted providers were required to record their data. The EHR system made
patient data available to primary care providers in real time and helped to reduce duplicated
services. Web-based EHRs also enabled care groups to benchmark the performance of care
providers, who could then learn from one another. In addition, the EHRs were used to generate
accountability reports for insurers and to inform the public about care groups’ achievements. In
interviews conducted by the National Institute of Public Health and the Environment, most
providers said that they perceived this greater transparency as the main success of the reform.
3. It optimized the value of clinical expertise. Care groups are led by providers, who use their clinical
knowledge directly in decisions to achieve efficient, high-quality care. Therefore, fewer low-value
services are purchased, and both overuse of unnecessary services and underuse of high-value
services are avoided. For instance, after bundled payments were introduced, the number of
routine check-ups went down for diabetes patients with well-controlled blood-glucose levels but
went up for patients who needed more-intensive monitoring. Also, diabetes patients who had no
abnormalities on their annual eye exam were switched to a biannual eye-exam schedule,
consistent with Dutch clinical-practice guidelines.
Challenges ahead
Despite its successes, the Dutch bundled-payment model faces three main challenges that are
relevant to U.S. policymakers:
The model is limited to primary care. Outpatient specialist care and inpatient care are still paid via
existing hospital-payment systems. This distinction was probably wise in the early stages of
implementation, as general practitioners (GPs) were being urged to adopt bundles. However, it
potentially encourages GPs to refer the more-complex (and more costly) patients to specialists.
Currently, some care groups are exploring whether to extend the care bundle to outpatient specialist
care and inpatient care.
Quality measures should focus more on outcomes. Despite the initial goal of improving patient
outcomes, most DFHCS quality measures still focus on process metrics, such as the percentage of
diabetes patients whose HbA1c levels were measured in the past 12 months. I expect current measures
to be replaced by measures that matter more to patients, such as those outlined by the International
Consortium for Health Outcomes Measurement.
Better payment models are needed. Having provider-led care groups assume financial risks has been
an important step in payment reform, but the Dutch health care system must move toward moredisruptive payment models that focus on caring for patients rather than merely treating disease.
Models like global payments, analogue to the Alternative Quality Contract, are receiving scrutiny in
the Netherlands. It might even be wise just to scale up the number of bundled-payment contracts for
the most prevalent chronic conditions before introducing more-disruptive payment models, but that
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4
option has not yet been actively considered. We may simply have to wait for a willing Dutch insurer
to take a chance. I am hopeful that the next step will come soon, so that Dutch providers that are
willing to take the lead are not discouraged.
For now, as U.S. policymakers aim to strengthen the primary-care orientation of payment models,
they should consider “going Dutch” — not by splitting the bill, but by bundling it.
Jeroen N. Struijs is a senior researcher at the National Institute of Public Health and the Environment in the
Netherlands. He is also a 2013–2014 Commonwealth Fund Harkness Fellow in Health Care Policy and Practice.
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Kessels et al. BMC Health Services Research (2015) 15:191
DOI 10.1186/s12913-015-0847-7
RESEARCH ARTICLE
Open Access
How to reform western care payment
systems according to physicians, policy
makers, healthcare executives and
researchers: a discrete choice experiment
Roselinde Kessels1*, Pieter Van Herck2, Eline Dancet2,3,4, Lieven Annemans5 and Walter Sermeus2
Abstract
Background: Many developed countries are reforming healthcare payment systems in order to limit costs and
improve clinical outcomes. Knowledge on how different groups of professional stakeholders trade off the merits
and downsides of healthcare payment systems is limited.
Methods: Using a discrete choice experiment we asked a sample of physicians, policy makers, healthcare
executives and researchers from Canada, Europe, Oceania, and the United States to choose between profiles of
hypothetical outcomes on eleven healthcare performance objectives which may arise from a healthcare payment
system reform. We used a Bayesian D-optimal design with partial profiles, which enables studying a large number
of attributes, i.e. the eleven performance objectives, in the experiment.
Results: Our findings suggest that (a) moving from current payment systems to a value-based system is supported
by physicians, despite an income trade-off, if effectiveness and long term cost containment improve. (b) Physicians
would gain in terms of overall objective fulfillment in Eastern Europe and the US, but not in Canada, Oceania and
Western Europe. Finally, (c) such payment reform more closely aligns the overall fulfillment of objectives between
stakeholders such as physicians versus healthcare executives.
Conclusions: Although the findings should be interpreted with caution due to the potential selection effects of
participants, it seems that the value driven nature of newly proposed and/or introduced care payment reforms is
more closely aligned with what stakeholders favor in some health systems, but not in others. Future studies,
including the use of random samples, should examine the contextual factors that explain such differences in
values and buy-in.
JEL classification: C90, C99, E61, I11, I18, O57
Keywords: Healthcare payment systems, Healthcare performance objectives, Physician incentive structures, Health
policy reform, Discrete choice experiment
* Correspondence: roselinde.kessels@uantwerpen.be
1
Faculty of Applied Economics, Department of Economics & StatUa Center
for Statistics, University of Antwerp, Prinsstraat 13, B-2000 Antwerpen,
Belgium
Full list of author information is available at the end of the article
© 2015 Kessels et al. This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://
creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Kessels et al. BMC Health Services Research (2015) 15:191
Background
Policy makers of many developed countries are trying to
strengthen the long term sustainability of healthcare by
reforming healthcare payment systems. They want to
replace or enhance salary and fee for service (FFS) payment systems by other incentive structures, such as pay
for performance, shared savings, partial capitation, and
bundled payment [1]. These incentives aim to reconcile
a broader spectrum of healthcare objectives varying
from quality, cost and equity to patient centeredness and
coordination of care.
The literature to date consists of about 130 effect
studies of healthcare payment reform, the majority of
them covering the US (50%) and the UK (45%). The
remaining studies are spread across Australia, Germany,
the Netherlands, Spain and Italy. Studies in Canada and
Eastern Europe are largely lacking. Results show that,
although reforms seem promising in the long term, short
term effects have been disappointing [2-4]. This could
partially be explained by growing pains, practical or
technical difficulties and the need for short term investments to make the new systems work [5-9]. Nevertheless, more fundamental impediments could be at
play. Enthusiasm from physicians and healthcare organizations is lacking as, in contrast to FFS payment
systems, new healthcare payment systems require
taking financial risks [10,11].
Physicians and healthcare executives are unlikely to
engage in a new healthcare payment system if they are
not in line with what they value. Knowledge on how
different groups of professional stakeholders trade off
the merits and downsides of healthcare payment systems
is limited. Are the new incentive structures a better
match with key priorities of healthcare providers, physicians in particular, even if financial security is at play?
Will priorities of physicians, policy makers and healthcare executives converge or diverge as a consequence of
the new payment systems? And are the answers to these
questions the same across geographical areas with a
different health system and context? For each of these
questions, we need in-depth knowledge of the values
and trade-offs associated with healthcare objectives.
In this paper, we describe the design and analysis
results of a discrete choice experiment (DCE) that we
performed to examine how improvements, deteriorations and status quo outcomes in healthcare performance objectives due to a payment system reform are
traded off by physicians, policy makers, healthcare executives and researchers from Canada, Eastern Europe,
Oceania, the US and Western Europe. The DCE is part
of a larger study that also includes the rating study of
Van Herck et al. [12] in which the same stakeholders
directly stated preference ratings for seven healthcare
payment systems. The DCE approach is, however, indirect,
Page 2 of 14
measuring stakeholder preferences for payment reform
outcomes on eleven health system performance objectives.
We use the analysis results of the DCE to compare goal
fulfillment and stakeholder alignment between current
and newly proposed payment structures.
Methods
The DCE method is a survey technique with a growing
use in healthcare to quantify people’s preferences by observing their stated choices in a number of hypothetical
scenarios, called choice sets [13-15]. Each choice set
consists of two or more competing options, out of which
respondents have to indicate the option they like better.
The options are also called profiles and are defined in
terms of a specified set of attributes or dimensions that
differ in a number of levels. The data from a DCE allow
the assessment of the relative importance of each attribute in the total value of each of the profiles under
study.
Conducting a DCE involves the following steps: (i)
identification of the attributes and attribute levels, (ii)
experimental design of the choice sets, (iii) questionnaire
development, (iv) study sample and (v) data analysis. We
discuss these steps in turn.
Identification of the attributes and attribute levels
As attributes for the DCE, we carefully selected eleven
health system performance objectives or domains shown
in Table 1. For each objective, we specified three possible
outcomes as levels, namely a ‘positive’, ‘negative’ and ‘no
change’ outcome.
To select the health system performance domains for
study in the DCE, we consulted the literature as well as
two expert panels. We interviewed 46 representatives of
the stakeholder groups of interest to gauge their opinion
about care payment systems and their outcomes [16].
Using a broadly exploratory approach, we identified 25
potentially relevant health system performance domains.
Based on literature review, we regrouped the performance domains and reduced them from 25 to 12. We then
asked 23 international care payment experts to rate each
of the 12 health system performance domains on a 5point scale in terms of their importance in health
policy decision making about care payment systems.
The importance rankings of the 12 performance domains led us to select 11 performance domains most
likely to influence the preferences for care payment
outcomes.
Experimental design of the choice sets
The DCE presented participants with 18 choice sets of
two alternative profiles with performance outcomes that
payment change in their health system would generate.
For each choice set, participants had to indicate the
Kessels et al. BMC Health Services Research (2015) 15:191
Page 3 of 14
Table 1 Healthcare system performance objectives or domains considered to be relevant to assess care payment
system effects
Performance objective
Definition
1. Clinical effectiveness and patient safety
The degree to which the level of health gain is maximized and harm to patients is
minimized as a consequence of care. This domain refers to the effect of the payment
scheme, and its sustainability, on patient outcome in a broad sense (life expectancy,
relief of pain, functional capacity, etc.).
2. Best practice service use
The degree to which services are provided based on scientific knowledge to all who
could benefit (avoiding underuse) and are refrained from being provided to those not
likely to benefit (avoiding overuse). This implies that (1) patients do not receive care
that cannot help them and/or the risks of which outweigh the benefits and (2) patients
reliably receive care where the known benefits outweigh the risks.
3. Care equity
The degree to which care and its optimal outcome are delivered and attained for all
people, without variation based on patient characteristics (such as gender, age, ethnicity,
geographical location and socioeconomic status), unless there is a valid clinical rationale.
4. Care coordination, teamwork and continuity
The degree to which provider contributions are well integrated to optimize the delivery
of care by the same healthcare provider throughout the course of care, with appropriate
and timely communication, referral and collaboration between providers (both within
and between provider organizations).
5. Patient centeredness
The degree to which care is respectful of and responsive to individual patient preferences
and values, ensuring that patient preferences and values guide major clinical decisions.
6. Timeliness
The degree to which waits and delays are avoided.
7. Short term cost containment and budget safety
The degree to which expenditure of financial resources is contained in short term. Short
term expenditure may not only be due to cost of care (including potential waste), but
also due to investment in system organization (e.g. cost of implementation).
8. Long term cost containment and budget safety
The degree to which expenditure of financial resources is contained in long term. Long
term expenditure may not only be due to cost of care (including potential waste), but
also due to maintenance of system organization (e.g. cost of measuring and updating).
9. Provider wellness
The degree to which provider wellness is sustained, improves or deteriorates, as affected
by job satisfaction, income (in)security, workload, autonomy and respect of professional
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