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Systematic Review
To assess the impact of different payment methods for healthcare providers working in outpatient healthcare settings on the quantity and quality of health service provision, patient outcomes, healthcare provider outcomes, cost of service provision, and adverse effects.
"Only one study in this review met the inclusion criteria of this evidence map (Kouides 1998):
'We are uncertain if adding [incentives for providers] improves immunisation rates amongst ambulatory Medicare patients aged 65 or older, compared with an existing payment method (MD 0.34, 95% CI −0.20 to 0.87; Analysis 2.1; very low-certainty evidence) (Kouides 1998).'
The authors state:
We included 27 studies in the review: 12 randomised trials, 13 controlled before‐and‐after studies, one interrupted time series, and one repeated measure study. Most healthcare providers were primary care physicians. Most of the payment methods were implemented by health insurance schemes in high‐income countries, with only one study from a low‐ or middle‐income country. The included studies were categorised into four groups based on comparisons of different payment methods.
(1) Pay for performance (P4P) plus existing payment methods comparedwith existing payment methods for healthcare providers working in outpatient healthcare settings
P4P incentives probably improve child immunisation status (RR 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate‐certainty evidence) and may slightly increase the number of patients who are asked more detailed questions on their disease by their pharmacist (MD 1.24, 95% CI 0.93 to 1.54; 454 patients; low‐certainty evidence). P4P may slightly improve primary care physicians' prescribing of guideline‐recommended antihypertensive medicines compared with an existing payment method (RR 1.07, 95% CI 1.02 to 1.12; 362 patients; low‐certainty evidence). We are uncertain about the effects of extra P4P incentives on mean blood pressure reduction for patients and costs for providing services compared with an existing payment method (very low‐certainty evidence).
(2) Fee for service (FFS) comparedwith existing payment methods for healthcare providers working in outpatient healthcare settings
We are uncertain about the effect of FFS on the quantity of health services delivered (outpatient visits and hospitalisations), patient health outcomes, and total drugs cost compared to an existing payment method due to very low‐certainty evidence.
(3) FFS mixed with existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings
FFS mixed payment method may increase the quantity of health services provided compared with an existing payment method (RR 1.37, 95% CI 1.07 to 1.76; low‐certainty evidence). We are uncertain about the effect of FFS mixed payment on quality of services provided, patient health outcomes, and health professional outcomes compared with an existing payment method due to very low‐certainty evidence.
(4) Enhanced FFS compared with FFS for healthcare providers working in outpatient healthcare settings
Enhanced FFS (higher FFS payment) probably increases child immunisation rates (RR 1.25, 95% CI 1.06 to 1.48; moderate‐certainty evidence). We are uncertain whether higher FFS payment results in more primary care visits and about the effect of enhanced FFS on the net expenditure per year on covered children with regular FFS (very low‐certainty evidence)."
The authors state:
"For healthcare providers working in outpatient healthcare settings, P4P or an increase in FFS payment level probably increases the quantity of health service provision (moderate‐certainty evidence), and P4P may slightly improve the quality of service provision for targeted conditions (low‐certainty evidence). The effects of changes in payment methods on health outcomes is uncertain due to very low‐certainty evidence. Information to explore the influence of specific payment method design features, such as the size of incentives and type of performance measures, was insufficient. Furthermore, due to limited and very low‐certainty evidence, it is uncertain if changing payment models without including additional funding for professionals would have similar effects."