Performance-based contracting for hospitals: a mixed methods analysis of impacts on patient outcomes, equity and efficiency in a middle income country

公共卫生部是黎巴嫩最大的住院保险机构，每年为52%的公民和约24万名住院患者提供保险。典型的患者是那些负担不起医疗保险、失业或个体户、年龄超过或患有慢性病(如糖尿病、高血压、癌症)的人。为了提供这些服务，卫生部与135家公立和私立医院进行了接触。自2001年以来，该部向医院支付的偿还率是根据医院认证程序的结果确定的。然而，在过去的几年里，越来越多的证据表明，这不是管理卫生部和医院之间关系的有效方法。重要的是，卫生部没有关于医院业绩的不完善信息。2014年，卫生部开始从仅以认证为基础的合同制度过渡到以绩效为基础的合同制度，包括患者的结果。本研究的主要目的是在卫生部和黎巴嫩的医院之间建立基于绩效的合同制度(PBC)，并评估其对患者和卫生系统的影响。这样的合同意味着，卫生部将通过向每位患者支付更高的基本费率来奖励表现更好的医院。我们将调查哪些因素可能会影响医院的表现，以及医院如何应对这一干预。在过去20年里，在卫生服务中开展了大量的PBC工作。然而，支持其对患者的益处和成本效益的证据呈现出好坏参半的结果。造成这种情况的主要原因之一是严格设计的研究数量有限。来自英国和美国的最新证据还发现，减少重新入院和死亡率等积极影响可能仅限于短期，并强调了建设和平委员会的衡量、背景和设计的重要性。在低/中等收入国家(LMIC)，证据仍然较为有限，尽管PBC很有希望，因为考虑到改善的潜力，它可能会对健康结果产生更大的影响。然而，这也意味着它可能会产生更大的意想不到的或负面的后果，在设计PBC时，应该非常小心地设计并密切监测影响。在设计PBC时，重要的是确定如何衡量绩效以及如何评估其影响。在我们的研究中，我们将在患者层面上研究特定情况下患者重新入院的变化，这可能表明治疗不足、医院获得性感染或其他原因。我们亦会研究每间医院入院病人的比例，以了解他们的年龄和患有慢性病的情况，因为有些医院可能会“挑剔”，避开病情较复杂的病人。我们还将开发一份患者满意度问卷，并用它来衡量患者的满意度，这将代表他们接受治疗的医院。在卫生系统/医院层面，我们将研究不同服务的使用情况和成本，以及每家医院入院病例的复杂程度(病例组合)。我们将比较实施PBC前后这些绩效指标的结果，并调查任何变化。我们亦会访问一些医院管理人员，以了解医院如何回应PBC，以及他们可能作出了哪些改变，以影响他们的表现，例如更好地应用临床指引、增加对医护人员的培训或鼓励等。我们会透过不同渠道，积极与持份者和公众分享我们的研究结果，包括发展知识翻译材料和举办研讨会及政策圆桌会议等活动。所获得的知识将用于为建设和平委员会在黎巴嫩的未来发展和小岛屿发展中国家的类似举措提供信息。

The Ministry of Public Health (MoPH) is the largest insurer for hospitalizations in Lebanon, covering 52% of citizens and about 240,000 hospital admissions annually. Typical patients are those who are unable to afford health insurance, are unemployed or self-employed, are older than 64 years, or have a chronic disease (e.g. diabetes, hypertension, cancer). To provide these services, the MoPH contacts with 135 public and private hospitals. Since 2001 the reimbursement rate paid to hospitals by the ministry was determined by the results of a hospital accreditation process. However, over the past several years evidence has accumulated that this was not an effective way to manage the relationship between the MoPH and hospitals. Importantly, the ministry has imperfect information on the performance of hospitals. In 2014 the MoPH began a transition away from the accreditation-only contracting system, and towards one based on performance, including patient outcomes.The main purpose of this research is to develop a performance-based contracting (PBC) system between the MoPH and hospitals in Lebanon, and evaluate its impact on patients and the health system. Such contracting means that the ministry would reward hospitals that perform better by paying them a higher base rate per patient. We will investigate what factors may affect hospital performance and how hospitals responded to this intervention.There has been much work on PBC in health services over the past two decades. However the evidence to support its benefit to patients and cost-effectiveness presents mixed results. One of the main reasons for this is the limited number of strongly designed studies. Recent evidence from England and the United States has also found that positive effects such as reduced readmissions and mortality may be limited to the short-term, and underlined the importance of PBC measurement, context and design. In low/middle-income countries (LMIC) evidence is still more limited, though PBC holds much promise as it may have larger impact on health outcomes given the potential to improve. However this also means it may have larger unintended or negative consequences, and should be designed with great care and close monitoring of impact.In designing PBC, it is important to determine how performance will be measured and how we would evaluate its impact. In our research, at the patient level we will look at changes in patient readmissions for specific conditions, which could indicate inadequate treatment, hospital-acquired infections, or other causes. We will also look at the proportion of patients admitted to each hospital in terms of their age and presence of chronic diseases, as some hospitals may 'cherry-pick' and avoid patients with more complex conditions. We will also develop a patient satisfaction questionnaire, and use it to measure the satisfaction of patients that would be representative of the hospital they were treated at. At the health system/hospital level we will look at the utilization and cost of different services, as well as how complex are the cases being admitted to each hospital (case-mix). We will compare the results for these performance indicators before and after implementation of PBC, and investigate any changes. We will also interview a sample of hospital managers to understand how hospitals responded to PBC and what changes they may have made to affect their performance, such as better application of clinical guidelines, increased training or incentives to the health workforce.We will actively share our research findings with stakeholders and the public through various channels including developing knowledge translation materials and events such as seminars and policy roundtables. The knowledge gained will be used to inform future PBC development in Lebanon and similar initiatives in LMICs.