By NextBestFitPay for activity on top of budgets
Pay extra for procedures beyond baseline volume to cut queues.
Pays for extra volume on top of budgets.
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This path
Pay for activity on top of budgets
Concrete changes if chosen
What would actually have to change in law, agencies, payment rules, or systems.
- Pay extra for procedures beyond baseline volume
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
- Longer waits if demand grows faster than capacity
Extra payment for procedures beyond baseline volume rewards throughput and cuts queues.
What it creates or worsens
- Raises spending or loosens control over it
Paying extra for procedures beyond baseline volume can increase spending.
- Low-value care and overtreatment
Extra payment beyond baseline volume creates an incentive to perform more procedures.
10 paths soften this
Evidence-based coverage decisionsLow-value care and overtreatmentChosenFeedback and clinician nudgesLow-value care and overtreatmentChosenModest copays with an income-based annual capUnderinsurance: covered, but can't afford to use itRejectedValue-based cost sharingUnderinsurance: covered, but can't afford to use itRejectedGlobal budgets for hospitalsU.S. prices are far higher than in other countriesChosenNo-fault compensation for medical injuryMalpractice system: slow, costly, and drives defensive medicineChosenNational health record and patient IDRecords don't follow patientsChosenSeparate public capital budget, planned regionallyUnder-investment in equipment and facilitiesChosenAccept somewhat slower adoptionSlower access to new drugs and technologyRejectedOnly flat, small charges on a few servicesCopays keep billing systems alive and still deter poorer patientsRejected
Who's affected
Who gains
- People with employer coverage
- Longer waits if demand grows faster than capacity: They are seen fastest today and would share one queue with everyone.
- People with ongoing or specialist care needs
- Longer waits if demand grows faster than capacity: They need specialists and procedures most often.
- Hospitals, clinics, and care organizations
- Low-value care and overtreatment: Per-service payments reward additional low-value care.
- Drug and device makers
- Low-value care and overtreatment: They sell devices and tests used in low-value care.
Who loses
- Taxpayers and public budgets
- Raises spending or loosens control over it: Public budgets pay the added spending.
- Low-value care and overtreatment: They pay for tests and treatments with little benefit.
- People with ongoing or specialist care needs
- Low-value care and overtreatment: Low-benefit tests and treatments expose them to harm.
- Health insurers, brokers, and their shareholders
- Low-value care and overtreatment: They pay for tests and treatments with little benefit.
Where it has been tried
- Sweden, Norway: Activity-based pay reduced waits.
- Norway: In Norway, hospital wait times to start treatment fell by 13% over four years to an average of 60 days in 2017, as the country combined activity-based funding with national waiting-time targets.Sources: The Commonwealth Fund (2017)