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Systematic Review
This Cochrane review aimed 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.
The reviewers 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. Of which only two groups fulfilled the outcome criteria for this evidence map.
(1) Pay for performance (P4P) plus existing payment methods compared with existing payment methods for healthcare providers working in outpatient healthcare settings: P4P incentives probably improve child immunisation status [Risk ratio (RR) 1.27, 95% confidence interval (CI) 1.19 to 1.36; 3760 patients; moderate‐certainty evidence].
2) Enhanced fee for service (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). The reviewers 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).
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.
There is a need for further well‐conducted research on payment methods for healthcare providers working in outpatient healthcare settings in low‐ and middle‐income countries; more studies comparing the impacts of different designs of the same payment method; and studies that consider the unintended consequences of payment interventions.