Peabody John W, Quimbo Stella, Florentino Jhiedon, Shimkhada Riti, Javier Xylee, Paculdo David, Jamison Dean, Solon Orville
Global Health Sciences, University of California, San Francisco, CA, USA.
QURE Healthcare, San Francisco, CA, USA.
Health Policy Plan. 2017 May 1;32(4):563-571. doi: 10.1093/heapol/czw179.
Should health systems invest more in access to care by expanding insurance coverage or in health care services including improving the quality of care? Comparing these options experimentally would shed light on the impact and cost-effectiveness of these strategies.
The Quality Improvement Demonstration Study (QIDS) was a randomized policy experiment conducted across 30 districts in the Philippines. The study had a control group and two policy intervention groups intended to improve the health of young children. The demand-side intervention in QIDS was universal health insurance coverage (UHC) for children aged 5 years or younger, and a supply-side intervention, a pay-for-performance (P4P) bonus for all providers who met pre-determined quality levels. In this paper, we compare the impacts of these policies from the QIDS experiment on childhood wasting by calculating DALYs averted per US$spent.
The direct per capita costs to implement UHC and P4P are US$4.08 and US$1.98 higher, respectively, compared to control. DALYs due to wasting were reduced by 334,862 in UHC and 1,073,185 in P4P. When adjustments are made for the efficiency of higher quality, the DALYS averted per US$ spent is similar in the two arms, 1.56 and 1.58 for UHC and P4P, respectively. Since the P4P quality improvements touches all patients seen by qualifying providers (32% in UHC versus 100% in P4P), there is a larger reduction in DALYs. With similar programmatic costs for either intervention, in this study, each US$spent under P4P yielded 1.52 DALYs averted compared to the standard program, while UHC yielded only a 0.50 DALY reduction.
P4P had a greater impact and was more cost-effective compared to UHC as measured by DALYs averted. While expanded insurance benefit ceilings affected only those who are covered, P4P incentivizes practice quality improvement regardless of whether children are insured or uninsured.
卫生系统应通过扩大保险覆盖范围来增加获得医疗服务的机会，还是应投资于包括提高医疗质量在内的医疗服务？通过实验比较这些选择将有助于了解这些策略的影响和成本效益。
质量改进示范研究（QIDS）是在菲律宾30个地区进行的一项随机政策实验。该研究有一个对照组和两个旨在改善幼儿健康的政策干预组。QIDS中的需求侧干预是为5岁及以下儿童提供全民健康保险（UHC），供应侧干预是为所有达到预定质量水平的提供者提供按绩效付费（P4P）奖金。在本文中，我们通过计算每花费1美元避免的伤残调整生命年（DALYs），比较QIDS实验中这些政策对儿童消瘦的影响。
与对照组相比，实施UHC和P4P的人均直接成本分别高出4.08美元和1.98美元。UHC组因消瘦导致的DALYs减少了334,862，P4P组减少了1,073,185。在对更高质量的效率进行调整后，两组每花费1美元避免的DALYs相似，UHC组和P4P组分别为1.56和1.58。由于P4P带来的质量改善惠及了符合条件的提供者所诊治的所有患者（UHC组为32%，P4P组为100%），DALYs的减少幅度更大。在本研究中，两种干预措施的项目成本相似，与标准项目相比，P4P每花费1美元可避免1.52个DALYs，而UHC仅减少0.50个DALYs。
以避免的DALYs衡量，与UHC相比，P4P产生的影响更大且成本效益更高。虽然扩大保险福利上限仅影响参保者，但P4P激励提高医疗质量，无论儿童是否参保。
