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- Eriksson, Thérèse, 1988-
(författare)
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Promises and pitfalls of value-based reimbursement in healthcare : A mixed method health economic approach
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Financial incentives can be an effective tool to influence behaviour in almost any context and healthcare is no exception. The healthcare market is, however complex, characterised by uncertainty, information asymmetry and multiple agency connections. The reach and limits of financial incentives in healthcare has been widely debated for decades. Some argue that financial incentives increase efficient use of scarce resources, while others voice that it provides a hotbed for unintended and unethical behaviour. A well-functioning value-based reimbursement programme (VBRP) should facilitate alignment between financial incentives and professional values to secure both efficient and equitable healthcare. This thesis explores the promises and pitfalls of value-based reimbursement in the context of a value-based reimbursement programme within elective spine surgery in Region Stockholm, Sweden. By using mixed methods, this thesis explores what incentives arise from introducing a value-based reimbursement programme and how these incentives affect the provision of healthcare services. This thesis consists of four papers. Paper I examines the performance of healthcare providers (spine surgery clinics) on patient-reported outcome measures after the introduction of a value-based reimbursement programme and whether it has any effect on case mix regarding clinical and socio-economic factors. Paper II examines how a value-based reimbursement programme affects the cost of elective spine surgery to a third party payer/regional authority. Paper III explores how the intended incentives of the reimbursement programme was perceived by healthcare providers. In Paper IV, institutional logics within healthcare-providing organisations are identified and how their centrality and compatibility affect the institutionalisation of a value-based reimbursement programme in Region Stockholm. The results show that the VBRP had no effect on patient-reported outcome measures but decreased the mean cost per surgery. Thus, elective spine surgery in Region Stockholm may be considered more effective after the introduction of the VBRP. The removal of a production ceiling allowed healthcare providers to surgically treat more patients than was previously possible. The volume increased by 22 per cent, and the total cost increased by 11 percent. No indications of discrimination against sicker patients were found. A higher value was generated in elective spine surgery after the introduction of the VBRP. The idea of a VBRP was aligned with professional values. However, not all incentives were perceived as intended. The focus on minimising costs of post-discharge care was perceived to have a negative impact on quality aspects of physiotherapy and nursing. Taken together, a well-designed VBRP has the potential to promote a holistic healthcare perspective through 1) the level to which healthcare providers are held accountable for healthcare provision that increase the willingness to collaborate across healthcare providers and medical disciplines, 2) a better overall picture of patients healthcare utilisation and 3) challenging the traditional structures and ideas within healthcare that quality foremost depends on the performance of physicians. However, there are also challenges that needs to be addressed, 1) functioning routines for communication and follow-up between healthcare providers and the regional health authority, 2) to get different professions within a traditional hierarchical organisation to cooperate on equal terms, and 3) to create IT systems that create transparency and an understanding of the reimbursement programme. Continuous communication between healthcare providers and the regional health authority is therefore crucial to make the incentives of the reimbursement programme meaningful.
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| 2. |
- Johannesen, Kasper, 1982-
(författare)
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The value of evaluating and implementing pharmaceuticals
- 2021
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Pharmaceuticals are a central part of high-quality health care and a resource for improving population health. However, high prices set by private companies who develop and own the rights to new pharmaceuticals question the value that they contribute to the health care system. Publicly funded health care systems need to get the most from limited health care resources, which has become even more apparent in recent years with ageing populations, rapid technological development, and more recently the impact of COVID-19. Reducing pharmaceutical prices increase the current value that they offer to health care systems, but price reduction also decreases incentives to develop future treatments. Hence, the health care systems must balance the objective of improving the value from the treatments available today and incentivising the development of future treatments. Governments and health care decision makers use a variety of policies to control prices and use of pharmaceuticals. However, these policies are rarely the focus of formal analysis and their effect on short- and long-term population health is often unclear. The aim of this thesis was to investigate how policies that control pharmaceutical prices and implementation impact population health and incentives for pharmaceutical research and development (R&D). The first study in this thesis outlines a framework for assessing the effect of pharmaceutical policies on population health and pharmaceutical earnings and shows that price reducing policies can increase the current value of pharmaceuticals to health care systems while lowering R&D incentives. The design of specific policies determines the impact as well as the distribution of the gains of lower prices across patients, health care providers, pharmacies, and other affected parties. The second study analyses the trade-off between accuracy and cost of the cost-effectiveness appraisals for pharmaceuticals by viewing it as a diagnostic test that aims to identify costeffective treatments. The study identifies some policy relevant conclusions, including that the process should be flexible over time and depend on characteristics of the treatment undergoing assessment. Study three, investigating the impact of regional implementation variation of the antiplatelet ticagrelor, found that an additional 1,100 Quality Adjusted Life Years (QALYs) could have been gained from achieving equal implementation across health care regions. This represents a value of SEK 285 million from avoiding regional implementation variation of ticagrelor (given a value of SEK 250,000 per QALY). The study also shows that avoiding delays due to sequential decisions on reimbursement, treatment guidelines, and funding could have significant value. Finally, the fourth study investigates the comparative effectiveness of ticagrelor using observational data collected as part of routine clinical care in the SWEDEHEART registry. The study finds similar reduction in mortality as observed in the pivotal randomised clinical trial of ticagrelor, the PLATO trial. Furthermore, the importance of appropriate methods for observational research on comparative effectiveness are demonstrated, highlighting the importance of using appropriate methods when investigating the effectiveness of treatments used in clinical practice. In conclusion, this thesis shows the importance of analysing and understanding the effect of policies that control price and implementation of pharmaceuticals, whether the goal is to maximise the value from currently available pharmaceuticals or to also incentivise the development of new pharmaceuticals. Although the value of improving implementation may not be as obvious or tangible as savings from lowering pharmaceutical prices, improving implementation may contribute more to population health than reinvesting potential savings from price reductions.
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