Moran Valerie, Jacobs Rowena
London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK,
J Ment Health Policy Econ. 2017 Jun 1;20(2):83-94.
Despite limited resources in mental health care, there is little research exploring variations in cost performance across mental health care providers. In England, a prospective payment system for mental health care based on patient needs has been introduced with the potential to incentivise providers to control costs. The units of payment under the new system are 21 care clusters. Patients are allocated to a cluster by clinicians, and each cluster has a maximum review period.
The aim of this research is to explain variations in cluster costs between mental health providers using observable patient demographic, need, social and treatment variables. We also investigate if provider-level variables explain differences in costs. The residual variation in cluster costs is compared across providers to provide insights into which providers may gain or lose under the new financial regime.
The main data source is the Mental Health Minimum Data Set (MHMDS) for England for the years 2011/12 and 2012/13. Our unit of observation is the period of time spent in a care cluster and costs associated with the cluster review period are calculated from NHS Reference Cost data. Costs are modelled using multi-level log-linear and generalised linear models. The residual variation in costs at the provider level is quantified using Empirical Bayes estimates and comparative standard errors used to rank and compare providers.
There are wide variations in costs across providers. We find that variables associated with higher costs include older age, black ethnicity, admission under the Mental Health Act, and higher need as reflected in the care clusters. Provider type, size, occupancy and the proportion of formal admissions at the provider-level are also found to be significantly associated with costs. After controlling for patient- and provider-level variables, significant residual variation in costs remains at the provider level.
The results suggest that some providers may have to increase efficiency in order to remain financially viable if providers are paid national fixed prices (tariffs) under the new payment system. Although the classification system for payment is not based on diagnosis, a limitation of the study is the inability to explore the effect of diagnosis due to poor coding in the MHMDS.
We find that some mental health care providers in England are associated with higher costs of provision after controlling for characteristics of service users and providers. These higher costs may be associated with higher quality care or with inefficient provision of care.
The introduction of a national tariff is likely to provide a strong incentive to reduce costs. Policies may need to consider safe-guarding local health economies if some providers make substantial losses under the new payment regime.
Future research should consider the relationship between costs and quality to ascertain whether reducing costs may potentially negatively impact patient outcomes.
尽管精神卫生保健资源有限，但很少有研究探讨精神卫生保健提供者之间成本效益的差异。在英国，已引入一种基于患者需求的精神卫生保健前瞻性支付系统，该系统有可能激励提供者控制成本。新系统下的支付单位是21个护理群组。临床医生将患者分配到一个群组，每个群组有最长审查期。
本研究的目的是利用可观察到的患者人口统计学、需求、社会和治疗变量，解释精神卫生提供者之间群组成本的差异。我们还调查提供者层面的变量是否能解释成本差异。比较各提供者之间群组成本的剩余差异，以深入了解哪些提供者在新的财务制度下可能获利或亏损。
主要数据源是2011/12年和2012/13年英国的精神卫生最低数据集（MHMDS）。我们的观察单位是在护理群组中花费的时间段，与群组审查期相关的成本根据国民保健服务参考成本数据计算。使用多级对数线性模型和广义线性模型对成本进行建模。使用经验贝叶斯估计对提供者层面成本的剩余差异进行量化，并使用比较标准误差对提供者进行排名和比较。
各提供者之间的成本差异很大。我们发现，与较高成本相关的变量包括年龄较大、黑人种族、根据《精神卫生法》入院以及护理群组中反映出的较高需求。还发现提供者类型、规模、床位占用率以及提供者层面正式入院的比例与成本显著相关。在控制了患者和提供者层面的变量后，提供者层面仍存在显著的成本剩余差异。
结果表明，如果在新的支付系统下按照国家固定价格（费率）向提供者支付费用，一些提供者可能需要提高效率以维持财务可行性。尽管支付分类系统并非基于诊断，但本研究存在一个局限性，即由于MHMDS编码不佳，无法探讨诊断的影响。
我们发现，在控制了服务使用者和提供者的特征后，英国的一些精神卫生保健提供者与较高的提供成本相关。这些较高的成本可能与更高质量的护理或护理提供效率低下有关。
引入国家费率可能会有力地激励降低成本。如果一些提供者在新的支付制度下遭受重大损失，政策可能需要考虑保护当地卫生经济。
未来的研究应考虑成本与质量之间的关系，以确定降低成本是否可能对患者结果产生潜在的负面影响。
