背景:更改医疗保健提供者的付款方式,包括绩效薪酬计划,越来越多地被政府使用,健康保险公司,和雇主帮助使财务激励与卫生系统目标保持一致。在这篇评论中,我们重点介绍了门诊医疗机构中所有类型的医疗保健提供者的支付方式和支付水平的变化。门诊医疗设置,广义上定义为“出院”护理,包括初级保健,对于卫生系统来说,减少使用更昂贵的医院服务很重要。
目的:评估在门诊医疗机构工作的医疗保健提供者的不同支付方式对提供医疗服务的数量和质量的影响,患者结果,医疗保健提供者的结果,提供服务的成本,和不利影响。
方法:我们搜索了CENTRAL,MEDLINE,Embase(搜索2019年3月5日),和其他几个数据库。此外,我们搜索了临床试验平台,灰色文学,筛选纳入研究的参考清单,对纳入研究进行了引用参考搜索,并联系研究作者以确定其他研究。我们从2020年8月的更新搜索中筛选了记录,任何潜在的相关研究都被归类为等待分类。
方法:随机试验,非随机试验,控制前后研究,中断的时间序列,和重复的措施研究,比较不同的支付方式为医疗服务提供者在门诊护理机构工作。
方法:我们使用了Cochrane预期的标准方法学程序。我们进行了结构化合成。我们首先对支付方式比较和结果进行了分类,然后描述了不同类型的支付方式对不同结果类别的影响。在可行的情况下,我们使用荟萃分析综合了同一类别下支付干预的效果。在无法进行荟萃分析的地方,我们已经报告了可用点估计的均值/中位数和全部范围。我们报告了二分结局的风险比(RR)和连续结局的相对差异(如百分比变化或平均差(MD))。
结果:我们在综述中纳入了27项研究:12项随机试验,13项对照前后研究,一个中断的时间序列,和一项重复测量研究。大多数医疗保健提供者是初级保健医生。大部分支付方式是由高收入国家的健康保险计划实施的,只有一项来自低收入或中等收入国家的研究。根据不同支付方式的比较,将纳入的研究分为四组。(1)与在门诊医疗机构中工作的医疗保健提供者的现有付款方式相比,按绩效付费(P4P)加上现有的付款方式P4P激励措施可能会改善儿童免疫状态(RR1.27,95%置信区间(CI)1.19至1.36;3760名患者;中度确定性证据),并且可能会略微增加药剂师对其疾病提出更详细问题的患者人数(MD1.24,95%CI0.93至1.54与现有的支付方法相比,P4P可能会稍微改善初级保健医生对指南推荐的抗高血压药物的处方(RR1.07,95%CI1.02至1.12;362名患者;低确定性证据)。与现有的付款方式相比,我们不确定额外的P4P激励措施对患者平均血压降低和提供服务成本的影响(确定性非常低的证据)。纳入研究中未报告与工作量或其他健康专业结果相关的结果。一项随机试验发现,与对照组相比,在P4P干预结束后,受激励的专业人员的表现没有持续.(2)服务费(FFS)与在门诊医疗机构工作的医疗保健提供者的现有付款方式相比,我们不确定FFS对提供的医疗服务数量(门诊就诊和住院)的影响,患者健康结果,以及由于确定性非常低的证据,与现有付款方式相比的总药品成本。在纳入的研究中未报告服务提供的质量和健康专业结果。一项随机试验报告说,通过FFS付费的医生可能比受薪医生看到更多的患者(低确定性证据),这可能意味着通过FFS提供了更多不必要的服务。(3)FFS与现有支付方式相比较,与现有支付方式相比较,与现有支付方式相比较,FFS与现有支付方式相比较,FFS混合支付方式可能会增加提供的医疗服务数量(RR1.37,95%CI1.07~1.76;低确定性证据)。我们不确定FFS混合支付对所提供服务质量的影响,患者健康结果,和卫生专业结果与现有的支付方式相比,由于确定性非常低的证据。纳入的研究未报告成本结果和不良反应。(4)与在门诊医疗机构工作的医疗保健提供者的FFS相比,增强的FFS(更高的FFS支付)可能会增加儿童免疫接种率(RR1.25,95%CI1.06至1.48;中等确定性证据)。我们不确定更高的FFS支付是否会导致更多的初级保健就诊,以及提高FFS对定期FFS覆盖儿童每年净支出的影响(确定性非常低的证据)。服务质量,患者结果,健康专业成果,纳入研究中未报告不良反应.
结论:对于在门诊医疗机构工作的医疗保健提供者,P4P或FFS支付水平的增加可能会增加医疗服务提供的数量(中度确定性证据),和P4P可能会稍微提高针对性条件的服务质量(低确定性证据)。由于确定性非常低的证据,支付方式的变化对健康结果的影响是不确定的。信息,探讨具体支付方式设计特点的影响,例如激励措施的规模和绩效指标的类型,是不够的。此外,由于证据有限且确定性非常低,不确定在不包括专业人员额外资金的情况下改变支付模式是否会产生类似的影响。有必要对低收入和中等收入国家在门诊医疗机构工作的医疗保健提供者的支付方式进行进一步的研究;更多的研究比较相同支付方式的不同设计的影响;以及考虑支付干预措施的意外后果的研究。
BACKGROUND: Changes to the method of payment for healthcare providers, including pay-for-performance schemes, are increasingly being used by governments, health insurers, and employers to help align financial incentives with health system goals. In this review we focused on changes to the method and level of payment for all types of healthcare providers in outpatient healthcare settings. Outpatient healthcare settings, broadly defined as \'out of hospital\' care including primary care, are important for health systems in reducing the use of more expensive hospital services.
OBJECTIVE: To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects.
METHODS: We searched CENTRAL, MEDLINE, Embase (searched 5 March 2019), and several other databases. In addition, we searched clinical trials platforms, grey literature, screened reference lists of included studies, did a cited reference search for included studies, and contacted study authors to identify additional studies. We screened records from an updated search in August 2020, with any potentially relevant studies categorised as awaiting classification.
METHODS: Randomised trials, non-randomised trials, controlled before-after studies, interrupted time series, and repeated measures studies that compared different payment methods for healthcare providers working in outpatient care settings.
METHODS: We used standard methodological procedures expected by Cochrane. We conducted a structured synthesis. We first categorised the payment methods comparisons and outcomes, and then described the effects of different types of payment methods on different outcome categories. Where feasible, we used meta-analysis to synthesise the effects of payment interventions under the same category. Where it was not possible to perform meta-analysis, we have reported means/medians and full ranges of the available point estimates. We have reported the risk ratio (RR) for dichotomous outcomes and the relative difference (as per cent change or mean difference (MD)) for continuous outcomes.
RESULTS: We included 27 studies in the review: 12 randomised trials, 13 controlled before-and-after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high-income countries, with only one study from a low- or middle-income country. The included studies were categorised into four groups based on comparisons of different payment methods. (1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate-certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low-certainty evidence). P4P may slightly improve primary care physicians\' prescribing of guideline-recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low-certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low-certainty evidence). Outcomes related to workload or other health professional outcomes were not reported in the included studies. One randomised trial found that compared to the control group, the performance of incentivised professionals was not sustained after the P4P intervention had ended. (2) Fee for service (FFS) compared with existing payment methods for healthcare providers working in outpatient healthcare settings We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low-certainty evidence. The quality of service provision and health professional outcomes were not reported in the included studies. One randomised trial reported that physicians paid via FFS may see more well patients than salaried physicians (low-certainty evidence), possibly implying that more unnecessary services were delivered through FFS. (3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low-certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low-certainty evidence. Cost outcomes and adverse effects were not reported in the included studies. (4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate-certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low-certainty evidence). Quality of service provision, patient outcomes, health professional outcomes, and adverse effects were not reported in the included studies.
CONCLUSIONS: For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate-certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low-certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low-certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low-certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects. There is a need for further well-conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low- and middle-income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.