Economists have long regarded healthcare as a unique and challenging area of economic activity on account of the specialized knowledge of healthcare professionals (HCPs) and the relatively weak market mechanisms that operate. This places a consideration of how motivation and incentives might influence performance at the center of research. As in other domains economists have tended to focus on financial mechanisms and when considering HCPs have therefore examined how existing payment systems and potential alternatives might impact on behavior. There has long been a concern that simple arrangements such as fee-for-service, capitation, and salary payments might induce poor performance, and that has led to extensive investigation, both theoretical and empirical, on the linkage between payment and performance. An extensive and rapidly expanded field in economics, contract theory and mechanism design, had been applied to study these issues. The theory has highlighted both the potential benefits and the risks of incentive schemes to deal with the information asymmetries that abound in healthcare. There has been some expansion of such schemes in practice but these are often limited in application and the evidence for their effectiveness is mixed. Understanding why there is this relatively large gap between concept and application gives a guide to where future research can most productively be focused.
Payment systems based on fixed prices have become the dominant model to finance hospitals across OECD countries. In the early 1980s, Medicare in the United States introduced the Diagnosis Related Groups (DRG) system. The idea was that hospitals should be paid a fixed price for treating a patient within a given diagnosis or treatment. The system then spread to other European countries (e.g., France, Germany, Italy, Norway, Spain, the United Kingdom) and high-income countries (e.g., Canada, Australia). The change in payment system was motivated by concerns over rapid health expenditure growth, and replaced financing arrangements based on reimbursing costs (e.g., in the United States) or fixed annual budgets (e.g., in the United Kingdom). A more recent policy development is the introduction of pay-for-performance (P4P) schemes, which, in most cases, pay directly for higher quality. This is also a form of regulated price payment but the unit of payment is a (process or outcome) measure of quality, as opposed to activity, that is admitting a patient with a given diagnosis or a treatment. Fixed price payment systems, either of the DRG type or the P4P type, affect hospital incentives to provide quality, contain costs, and treat the right patients (allocative efficiency). Quality and efficiency are ubiquitous policy goals across a range of countries. Fixed price regulation induces providers to contain costs and, under certain conditions (e.g., excess demand), offer some incentives to sustain quality. But payment systems in the health sector are complex. Since its inception, DRG systems have been continuously refined. From their initial (around) 500 tariffs, many DRG codes have been split in two or more finer ones to reflect heterogeneity in costs within each subgroup. In turn, this may give incentives to provide excessive intensive treatments or to code patients in more remunerative tariffs, a practice known as upcoding. Fixed prices also make it financially unprofitable to treat high cost patients. This is particularly problematic when patients with the highest costs have the largest benefits from treatment. Hospitals also differ systematically in costs and other dimensions, and some of these external differences are beyond their control (e.g., higher cost of living, land, or capital). Price regulation can be put in place to address such differences. The development of information technology has allowed constructing a plethora of quality indicators, mostly process measures of quality and in some cases health outcomes. These have been used both for public reporting, to help patients choose providers, but also for incentive schemes that directly pay for quality. P4P schemes are attractive but raise new issues, such as they might divert provider attention and unincentivized dimensions of quality might suffer as a result.
Jun Li and Edward C. Norton
Pay-for-performance programs have become a prominent supply-side intervention to improve quality and decrease spending in health care, touching upon long-term care, acute care, and outpatient care. Pay-for-performance directly targets long-term care, with programs in nursing homes and home health. Indirectly, pay-for-performance programs targeting acute care settings affect clinical practice for long-term care providers through incentives for collaboration across settings. As a whole, pay-for-performance programs entail the identification of problems it seeks to solve, measurement of the dimensions it seeks to incentivize, methods to combine and translate performance to incentives, and application of the incentives to reward performance. For the long-term care population, pay-for-performance programs must also heed the unique challenges specific to the sector, such as patients with complex health needs and distinct health trajectories, and be structured to recognize the challenges of incentivizing performance improvement when there are multiple providers and payers involved in the care delivery. Although empirical results indicate modest effectiveness of pay-for-performance in long-term care on improving targeted measures, some research has provided more clarity on the role of pay-for-performance design on the output of the programs, highlighting room for future research. Further, because health care is interconnected, the indirect effects of pay-for-performance programs on long-term care is an underexplored topic. As the scope of pay-for-performance in long-term care expands, both within the United States and internationally, pay-for-performance offers ample opportunities for future research.