Program in Health Services and Systems Research, Duke-NUS Medical School, Singapore 169857, Singapore.
Department of Medicine, Duke University, Durham, NC 27708, USA.
Int J Environ Res Public Health. 2023 Mar 4;20(5):4581. doi: 10.3390/ijerph20054581.
For several decades, health systems in developed countries have faced rapidly rising healthcare costs without concomitant improvements in health outcomes. Fee for service (FFS) reimbursement mechanisms (RMs), where health systems are paid based on volume, contribute to this trend. In Singapore, the public health service is trying to curb rising healthcare costs by transitioning from a volume-based RM to a capitated payment for a population within a geographical catchment area. To provide insight into the implications of this transition, we developed a causal loop diagram (CLD) to represent a causal hypothesis of the complex relationship between RM and health system performance. The CLD was developed with input from government policymakers, healthcare institution administrators, and healthcare providers. This work highlights that the causal relationships between government, provider organizations, and physicians involve numerous feedback loops that drive the mix of health services. The CLD clarifies that a FFS RM incentivizes high margin services irrespective of their health benefits. While capitation has the potential to mitigate this reinforcing phenomenon, it is not sufficient to promote service value. This suggests the need to establish robust mechanisms to govern common pool resources while minimizing adverse secondary effects.
几十年来，发达国家的医疗体系面临着医疗成本的快速增长，而健康状况却没有相应改善。按服务量付费（FFS）的报销机制（RMs）是导致这一趋势的原因之一，这种机制下，医疗体系的报酬是基于服务量的。在新加坡，公共医疗服务机构正试图通过从基于服务量的 RM 向地理服务区内人口的人头付费过渡来控制医疗成本的上升。为了深入了解这一转变的影响，我们开发了一个因果关系图（CLD）来表示 RM 和医疗体系绩效之间复杂关系的因果假设。该 CLD 是在政府政策制定者、医疗机构管理人员和医疗服务提供者的投入下开发的。这项工作强调了政府、医疗机构和医生之间的因果关系涉及到许多反馈循环，这些循环推动了医疗服务的组合。CLD 阐明了 FFS RM 激励高利润服务，而不管其健康效益如何。虽然人头付费有可能减轻这种强化现象，但不足以促进服务价值。这表明有必要建立健全的机制来管理共同资源，同时尽量减少不利的二次影响。
