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Medwave 2020;20(9):e8041 doi: 10.5867/medwave.2020.09.8041
Characterization and analysis of the basic elements of health payment mechanisms and their most frequent types
Daniela Paredes-Fernández, Rony Lenz-Alcayaga, Karla Hernández-Sánchez, Jael Quiroz-Carreño
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Key Words: reimbursement mechanisms, insurance, health, reimbursement

Abstract

Introduction
Healthcare systems are developed in imperfect scenarios, in which there are constant failures (uncertainty, information asymmetry, agency relationship problem, and supply-induced demand). These failures, based on the imperfection of the sector, determine the relationships and incentives between the actors. It is within this context that payment mechanisms regulate aspects of the system behavior and incentives, acting as instruments for the purchasing of health care from providers, mediated by health insurance on behalf of users.

Objective
To characterize the basic elements of most frequent payment mechanisms to help providers in their relationship with payers.

Methods
A review of the evidence was conducted in PubMed, Google, Google Scholar, and strategic snowball selection. Payment mechanisms consist of three classical microeconomics variables, fixed or variable: price, quantity, and expense. Time dimensions are used to analyze their attributes and effects. Different mechanisms emerge from the combination of these variables.

Results
Among the most used are: Fee-For-Service, Global Budget, Bundled Payments, Diagnosis-Related Groups, Per-capita, Performance Pay, and Risk-Sharing Agreements. A fourth has also gained importance: Financial Risk.

Conclusions
Payment mechanisms are essential to link health efforts with clinical practice. They make it possible to regulate relationships between insurers, providers, and users, which, depending on the architecture of the mechanism, can become beneficial or hinder the fulfillment of the objectives of the health system.


 

No English version is available for this article.

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Introducción
Los sistemas de salud se desarrollan en ámbitos complejos y con fallas constantes (incertidumbre, asimetría de información, problema de relación de agencia e inducción de demanda). Estas fallas determinan las relaciones e incentivos entre los actores y se basan en la imperfección del sector. Frente a ello, los mecanismos de pago regulan aspectos del comportamiento e incentivos del sistema, participando como instrumentos de compra de atenciones de salud a prestadores, mediados por los seguros de salud en representación de los usuarios.

Objetivo
Caracterizar los elementos básicos de las tipologías más frecuentes de los mecanismos de pago con el propósito de para apoyar la labor de los prestadores en su relación con pagadores.

Métodos
Se condujo una revisión dirigida de la evidencia en PubMed, Google, Google Scholar y selección estratégica en bola de nieve. Los mecanismos de pago están conformados por tres variables microeconómicas clásicas fijas o variables: precio, cantidad y gasto; y dimensiones temporales utilizadas para analizar sus atributos y efectos. De la combinación de estas variables surgen distintos mecanismos.

Resultados
Entre los más utilizados se describen: pago por servicio, presupuesto global, Bundled Payments, grupos relacionados de diagnóstico, per cápita, pago por desempeño y acuerdos de riesgo compartido. Dentro de sus variables ha cobrado importancia una cuarta, el riesgo financiero.

Conclusiones
Los mecanismos de pago resultan esenciales para concatenar esfuerzos sanitarios con la práctica clínica. Permiten regular relaciones entre seguros, prestadores y usuarios. Dependiendo de la arquitectura del mecanismo, estas pueden tornarse beneficiosas o entorpecer el cumplimiento de los objetivos del sistema sanitario.

Authors: Daniela Paredes-Fernández[1], Rony Lenz-Alcayaga[1], Karla Hernández-Sánchez[2], Jael Quiroz-Carreño[3]

Affiliation:
[1] Núcleo Académico Instituto de Salud Pública, Universidad Nacional Andrés Bello, Santiago, Chile
[2] Unidad de Revisión de Evidencia, Lenz Consultores, Santiago, Chile
[3] Facultad de Medicina, Universidad de Chile, Santiago, Chile

E-mail: rony.lenz@unab.cl

Author address:
[1] Fernández Concha #700
Las Condes, Santiago
Chile
Código postal: 7591538

Citation: Paredes-Fernández D, Lenz-Alcayaga R, Hernández-Sánchez K, Quiroz-Carreño J. Characterization and analysis of the basic elements of health payment mechanisms and their most frequent types. Medwave 2020;20(9):e8041 doi: 10.5867/medwave.2020.09.8041

Submission date: 19/5/2020

Acceptance date: 7/9/2020

Publication date: 1/10/2020

Origin: Not commissioned

Type of review: Externally peer-reviewed by three reviewers, double-blind

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Arrow K. Uncertainty and the welfare economics of medical care. Am Econ Rev 1963;53. | CrossRef |

Kutzin J. A descriptive framework for country-level analysis of health care financing arrangements. Health Policy. 2001 Jun;56(3):171-204. | CrossRef | PubMed |

Miller HD. Creating payment systems to accelerate value-driven health care: Issues and options for policy reform. 2007. [On line] | Link |

Barber SL, Lorenzoni L, Ong P. Price Setting and Price Regulation in Health Care. Ginebra, Suiza.: 2019. | CrossRef |

Kofi M. Healthcare Provider-Payment Mechanisms: A Review of Literature. J Behav Econ Financ Entrep Account Transp 2014;2:41–6. | Link |

Cashin C, Ankhbayar B, Thi-Phuong H, et al. Assessing health provider payment systems: Practical Guide for Countries Moving Toward Universal Health Coverage. 2015. [On line] | Link |

Londoño JL, Frenk J. Pluralismo estructurado: Hacia un modelo innovador para la reforma de los sistemas de salud en América Latina. Inter-American Dev Bank, Off Chief Econ No 353 1997;:1–32. [On line] | Link |

Joint Learning Network for Universal Health Coverage. Assessing Health Provider Payment Systems: A Practical Guide for Countries Working Toward Universal Health Coverage. Washington, DC: Results for Development Institute 2015. [On line] | Link |

Jegers M, Kesteloot K, De Graeve D, Gilles W. A typology for provider payment systems in health care. Health Policy. 2002 Jun;60(3):255-73. | CrossRef | PubMed |

Cromwell J, Trisolini MG, Pope GC, et al. Pay for Performance in Health Care: Methods and Approaches. 2011. | CrossRef |

Alshreef A. Provider Payment Mechanisms: Effective Policy Tools for Achieving Universal and Sustainable Healthcare Coverage. Online Fir. IntechOpen 2019. | CrossRef |

Tsai Y. Payments and Utilization of Immunization Services Among Children Enrolled in Fee-for-Service Medicaid. Med Care. 2018 Jan;56(1):54-61. | CrossRef | PubMed |

DeGregorio G, Manga S, Kiyang E, Manjuh F, Bradford L, Cholli P, et al. Implementing a Fee-for-Service Cervical Cancer Screening and Treatment Program in Cameroon: Challenges and Opportunities. Oncologist. 2017 Jul;22(7):850-859. | CrossRef | PubMed |

Mcintyre D, Kutzin J. Health financing country diagnostic: a foundation for national strategy development. WHO 2016. [On line] | Link |

Berenson RA, Upadhyay D, Delbanco S, et al. A Typology of Payment Methods. Washington, DC. EE.UU.: 2016. [On line] | Link |

Alvarez B, Pellisé L, Lobo F. Sistemas de pago a prestadores de servicios de salud en países de América Latina y de la OCDE [Payment systems for health care providers in Latin America and OECD countries]. Rev Panam Salud Publica. 2000 Jul-Aug;8(1-2):55-70. Spanish. | CrossRef | PubMed |

Chen B, Fan VY. Global Budget Payment: Proposing the CAP Framework. Inquiry. 2016 Sep 28;53:0046958016669016. | CrossRef | PubMed |

Telyukov A. El pago prospectivo por caso hospitalario en América Latina: Una guía metodológica. Partnershi. 2001. [On line] | Link |

Chen B, Fan VY. Strategic Provider Behavior Under Global Budget Payment with Price Adjustment in Taiwan. Health Econ. 2015 Nov;24(11):1422-36. | CrossRef | PubMed |

Landon BE, Roberts DH. Reenvisioning specialty care and payment under global payment systems. JAMA. 2013 Jul 24;310(4):371-2. | CrossRef | PubMed |

Song Z, Rose S, Safran DG, Landon BE, Day MP, Chernew ME. Changes in health care spending and quality 4 years into global payment. N Engl J Med. 2014 Oct 30;371(18):1704-14. | CrossRef | PubMed |

Benavides P, Castro R, Jones I. Sistema Público de Salud, Situación actual y proyecciones fiscales 2013- 2050. Dirección de Presupuestos del Ministerio de Hacienda 2013. [On line] | Link |

Fan C, Chen K, Kan K. The design of payment systems for physicians under global budget – an experimental study. J Econ Behav Organ 1998;34:295–311. | CrossRef |

Tsai WC, Kung PT, Chang WC. Influences of market competition on dental care utilization under the global budget payment system. Community Dent Oral Epidemiol. 2007 Dec;35(6):459-64. | CrossRef | PubMed |

Lenz R. Pago Asociado a Diagnóstico: Breve Reseña. Cuad Econ 1995;95:105–11. | Link |

FONASA, Subdepartamento de Plan de Beneficios. Estudio de costos prestaciones de salud: Informe final. Santiago, Chile.: 2015. | Link |

Departamento de Economía de la Salud. Minsal. Anexo: Canastas Valoradas EVC-2015. 2016. [On line] | Link |

de Bakker DH, Struijs JN, Baan CB, Raams J, de Wildt JE, Vrijhoef HJ, et al. Early results from adoption of bundled payment for diabetes care in the Netherlands show improvement in care coordination. Health Aff (Millwood). 2012 Feb;31(2):426-33. | CrossRef | PubMed |

Siddiqi A, White PB, Mistry JB, Gwam CU, Nace J, Mont MA, et al. Effect of Bundled Payments and Health Care Reform as Alternative Payment Models in Total Joint Arthroplasty: A Clinical Review. J Arthroplasty. 2017 Aug;32(8):2590-2597. | CrossRef | PubMed |

Froimson MI, Rana A, White RE Jr, Marshall A, Schutzer SF, Healy WL, et al. Bundled payments for care improvement initiative: the next evolution of payment formulations: AAHKS Bundled Payment Task Force. J Arthroplasty. 2013 Sep;28(8 Suppl):157-65. | CrossRef | PubMed |

Sood N, Huckfeldt PJ, Escarce JJ, Grabowski DC, Newhouse JP. Medicare's bundled payment pilot for acute and postacute care: analysis and recommendations on where to begin. Health Aff (Millwood). 2011 Sep;30(9):1708-17. | CrossRef | PubMed |

Conferencia Interamericana de Seguridad Social. Los grupos relacionados de diagnóstico (GRD) para ajustar los mecanismos de pago a proveedores de los sistemas de salud. Documento procedente de CISS. 2005.

Ministerio de Sanidad y Consumo. Análisis y desarrollo de los GDR en el Sistema Nacional de Salud. Madrid: 1999. [On line] | Link |

Información y Estadística Sanitarias. Ministerio de Sanidad Consumo y Bienestar Social. Estimación de pesos y costes de los procesos hospitalarios en el Sistema Nacional de Salud: metodología y principales resultados. Proyecto 2017. 2019. [On line] | Link |

Zapata M. Importancia Del Sistema GRD para Alcanzar La Eficiencia Hospitalaria. Rev Médica Clínica Las Condes 2018;29:347–52. | CrossRef |

Laguna JY. Calidad de la codificación de los procedimientos quirúrgicos y su influencia en los grupos relacionados con el diagnóstico. papeles médicos 2005;15:10–6. | Link |

Jackson T, Dimitropoulos V, Madden R, Gillett S. Australian diagnosis related groups: Drivers of complexity adjustment. Health Policy. 2015 Nov;119(11):1433-41. | CrossRef | PubMed |

Cleverley W, Cleverley J. Financial Environment of Healthcare Organizations. In: Essentials of Health Care Finance. Burlington, Massachusetts: : Jones & Bartlett 2018. 31–95.

Mikkola H, Keskimäki I, Häkkinen U. DRG-related prices applied in a public health care system--can Finland learn from Norway and Sweden? Health Policy. 2002 Jan;59(1):37-51. | CrossRef | PubMed |

Águila R A, Muñoz D MA, Sepúlveda S V. Experiencia en el desarrollo e implementación de la metodología de grupos relacionados por diagnóstico en un hospital universitario chileno. Evaluación a diez años de funcionamiento [Implementation of diagnosis related groups methodology in a university hospital]. Rev Med Chil. 2019 Dec;147(12):1518-1526. Spanish. | CrossRef | PubMed |

Reynaldos-Grandón K, Saiz-Alvarez JM, Molina-Muñoz Y. Competencias profesionales, gestión clínica y grupos relacionados de diagnósticos. El caso de hospitales públicos chilenos [Professional competences, clinical management and diagnostic related groups in Chilean public hospitals]. Rev Salud Publica (Bogota). 2018 Jul-Aug;20(4):472-478. Spanish. | CrossRef | PubMed |

ASIST, MINSAL. Norma IR-GRD MINSAL: Proceso de construcción y resultados de la Norma IR GRD 2014. Santiago, Chile.: 2015.

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July 2022, Vol 22, Issue 6
icon Research papers
Association of biomarkers and severity of COVID-19: A crosssectional study

Systematization of initiatives in sexual and reproductive health about good practices criteria in response to the COVID-19 pandemic in primary health care in Chile

Clinical, psychological, social, and family characterization of suicidal behavior in Chilean adolescents: a multiple correspondence analysis

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