Salet Newel, Buijck Bianca I, van Dam-Nolen Dianne H K, Hazelzet Jan A, Dippel Diederik W J, Grauwmeijer Erik, Schut F T, Roozenbeek Bob, Eijkenaar Frank
Erasmus School of Health Policy & Management, Erasmus University, NL.
Rotterdam Stroke Service, The Netherlands.
Int J Integr Care. 2023 Aug 10;23(3):7. doi: 10.5334/ijic.7566. eCollection 2023 Jul-Sep.
To address issues related to suboptimal insight in outcomes, fragmentation, and increasing costs, stakeholders are experimenting with value-based payment (VBP) models, aiming to facilitate high-value integrated care. However, insight in how, why and under what circumstances such models can be successful is limited. Drawing upon realist evaluation principles, this study identifies context factors and associated mechanisms influencing the introduction of VBP in stroke care.
Existing knowledge on context-mechanism relations impacting the introduction of VBP programs (in real-world settings) was summarized from literature. These relations were then tested, refined, and expanded based on a case study comprising interviews with representatives from organizations involved in the introduction of a VBP model for integrated stroke care in Rotterdam, the Netherlands.
Facilitating factors were pre-existing trust-based relations, shared dissatisfaction with the status quo, regulatory compatibility and simplicity of the payment contract, gradual introduction of down-side risk for providers, and involvement of a trusted third party for data management. Yet to be addressed barriers included friction between short- and long-term goals within and among organizations, unwillingness to forgo professional and organizational autonomy, discontinuity in resources, and limited access to real-time data for improving care delivery processes.
Successful payment and delivery system reform require long-term commitment from all stakeholders stretching beyond the mere introduction of new models. Careful consideration of creating the 'right' contextual circumstances remains crucially important, which includes willingness among all involved providers to bear shared financial and clinical responsibility for the entire care chain, regardless of where care is provided.
为解决与结果洞察力欠佳、碎片化及成本不断增加相关的问题，利益相关者正在试验基于价值的支付（VBP）模式，旨在促进高价值的综合护理。然而，对于此类模式如何、为何以及在何种情况下能够成功的了解有限。本研究借鉴现实主义评价原则，确定影响中风护理中引入VBP的背景因素及相关机制。
从文献中总结了关于影响（现实世界环境中）VBP项目引入的背景 - 机制关系的现有知识。然后基于一项案例研究对这些关系进行测试、完善和扩展，该案例研究包括对参与荷兰鹿特丹综合中风护理VBP模式引入的组织代表进行访谈。
促进因素包括预先存在的基于信任的关系、对现状的共同不满、支付合同的监管兼容性和简单性、逐步为提供者引入下行风险，以及由受信任的第三方参与数据管理。有待解决的障碍包括组织内部和组织之间短期与长期目标的冲突、不愿放弃专业和组织自主权、资源的不连续性，以及获取用于改善护理提供流程的实时数据有限。
成功的支付和服务提供系统改革需要所有利益相关者做出长期承诺，而不仅仅是引入新模式。认真考虑创造“正确的”背景环境仍然至关重要，这包括所有参与的提供者愿意为整个护理链承担共同的财务和临床责任，无论护理在何处提供。
