By NextBestFitRisk adjustment plus outcome monitoring
Pay more per patient for sicker patients, ban patient selection, and monitor access and outcomes publicly.
Outcome monitoring for budget-funded hospitals.
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This path
Risk adjustment plus outcome monitoring
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Risk-adjust capitated payments
- Monitor access and outcomes
Effects
Each effect has its own page: the evidence, the case that it is or isn't a real cost, and whom it affects.
What it fixes
- Paying a fixed amount per patient rewards doing less
Higher payments for sicker patients, a ban on patient selection, and public access and outcome monitoring reduce avoidance and make payments fairer.
What it creates or worsens
- Adds paperwork, coordination, or complexity
Adjusting payments for patient sickness and monitoring access and outcomes adds complexity.
- Targets and quality metrics invite gaming
Higher payments for sicker patients create a risk of upcoding.
Who's affected
Who gains
- People with ongoing or specialist care needs
- Paying a fixed amount per patient rewards doing less: Fixed payments encourage avoiding sick patients or providing less care.
- Hospitals, clinics, and care organizations
- Targets and quality metrics invite gaming: They can benefit by changing referral dates, avoiding sick patients, or upcoding.
Who loses
- Hospitals, clinics, and care organizations
- Paying a fixed amount per patient rewards doing less: They keep the difference when care costs less than fixed payments.
- Health insurers, brokers, and their shareholders
- Paying a fixed amount per patient rewards doing less: They keep the difference when care costs less than fixed payments.
- People with ongoing or specialist care needs
- Targets and quality metrics invite gaming: Gaming wait-time and quality measures undermines their intended protection.
Where it has been tried
- UK Quality and Outcomes Framework: Pay-for-performance in general practice; improvements leveled off and some gaming occurred.
- United Kingdom: A 2011 study states that approximately 25% of UK GP income was tied to QOF quality targets and describes exception reporting as a safeguard against inappropriate or excessive treatment.