Tsiachristas Apostolos, Dikkers Carolien, Boland Melinde R S, Rutten-van Mölken Maureen P M H
Institute for Medical Technology Assessment, Department of Health Policy and Management, Erasmus University Rotterdam, The Netherlands.
Health Policy. 2013 Dec;113(3):296-304. doi: 10.1016/j.healthpol.2013.07.007. Epub 2013 Aug 12.
The rising burden of chronic conditions has led several European countries to reform healthcare payment schemes. This paper aimed to explore the adoption and success of payment schemes that promote integration of chronic care in European countries. A literature review was used to identify European countries that employed pay-for-coordination (PFC), pay-for-performance (PFP), and bundled payment schemes. Existing evidence from the literature was supplemented with fifteen interviews with chronic care experts in these countries to obtain detailed information regarding the payment schemes, facilitators and barriers to their implementation, and their perceived success. Austria, France, England, the Netherlands, and Germany have implemented payment schemes that were specifically designed to promote the integration of chronic care. Prominent factors facilitating implementation included stakeholder cooperation, adequate financial incentives for stakeholders, and flexible task allocation among different care provider disciplines. Common barriers to implementation included misaligned incentives across stakeholders and gaming. The implemented payment schemes targeted different stakeholders (e.g. individual caregivers, multidisciplinary organizations of caregivers, regions, insurers) in different countries depending on the structure and financing of each health care system. All payment reforms appeared to have changed the structure of chronic care delivery. PFC, as it was implemented in Austria, France and Germany, was perceived to be the most successful in increasing collaboration within and across healthcare sectors, whereas PFP, as it was implemented in England and France, was perceived most successful in improving other indicators of the quality of the care process. Interviewees stated that the impact of the payment reforms on healthcare expenditures remained questionable. The success of a payment scheme depends on the details of the specific implementation in a particular country, but a combination of the schemes may overcome the barriers of each individual scheme.
慢性病负担的不断加重促使几个欧洲国家对医疗支付方案进行改革。本文旨在探讨在欧洲国家推行促进慢性病护理整合的支付方案的采用情况及成效。通过文献综述来确定采用按协调付费（PFC）、按绩效付费（PFP）和捆绑支付方案的欧洲国家。文献中的现有证据通过对这些国家的15位慢性病护理专家进行访谈得到补充，以获取有关支付方案、实施的促进因素和障碍以及他们所认为的成效的详细信息。奥地利、法国、英国、荷兰和德国已经实施了专门设计用于促进慢性病护理整合的支付方案。促进实施的突出因素包括利益相关者的合作、对利益相关者的充足经济激励以及不同护理提供者学科之间灵活的任务分配。实施的常见障碍包括利益相关者之间激励措施不一致和博弈行为。根据每个医疗系统的结构和融资情况，不同国家实施的支付方案针对不同的利益相关者（如个体护理人员、多学科护理人员组织、地区、保险公司）。所有支付改革似乎都改变了慢性病护理的提供结构。在奥地利、法国和德国实施的PFC被认为在增加医疗保健部门内部和之间的合作方面最为成功，而在英国和法国实施的PFP被认为在改善护理过程质量的其他指标方面最为成功。受访者表示，支付改革对医疗保健支出的影响仍然存在疑问。支付方案的成功取决于特定国家具体实施的细节，但多种方案的结合可能会克服每个单独方案的障碍。
