Intervention Review

Target payments in primary care: effects on professional practice and health care outcomes

  1. Antonio Giuffrida1,*,
  2. Toby Gosden2,
  3. Frode Forland3,
  4. Ivar Kristiansen4,
  5. Michelle Sergison5,
  6. Brenda Leese2,
  7. Lone Pedersen6,
  8. Matthew Sutton7

Editorial Group: Cochrane Effective Practice and Organisation of Care Group

Published Online: 21 JAN 2009

Assessed as up-to-date: 1 SEP 1999

DOI: 10.1002/14651858.CD000531

Database Title

Additional Information

How to Cite

Giuffrida A, Gosden T, Forland F, Kristiansen I, Sergison M, Leese B, Pedersen L, Sutton M. Target payments in primary care: effects on professional practice and health care outcomes. Cochrane Database of Systematic Reviews 1999, Issue 4. Art. No.: CD000531. DOI: 10.1002/14651858.CD000531.

Author Information

  1. 1

    Inter-American Development Bank, Social Programs Division, Region 3, Washington DC, USA

  2. 2

    University of Manchester, National Primary Care Research and Development Centre, Manchester, UK

  3. 3

    Norwegian Board of Health, Department of Public Health and International Affairs, N-0032 Oslo, Norway

  4. 4

    University of Oslo, Institute of Health Management and Health Economics, Oslo, Norway

  5. 5

    Huddersfield NHS Trust, Huddersfield Royal Infirmary, Clinical Development, Lindley, Huddersfield, UK

  6. 6

    Lancaster, Lancashire, UK

  7. 7

    University of York, Centre for Health Economics, York, Yorkshire, UK

*Antonio Giuffrida, Social Programs Division, Region 3, Inter-American Development Bank, 1300 New York Avenue, NW, Stop W0502, Washington DC, 20577, USA. antoniogi@iadb.org.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 21 JAN 2009

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

The method by which physicians are paid may affect their professional practice. Although payment systems may be used to achieve policy objectives (e.g. improving quality of care, cost containment and recruitment to under-served areas), little is known about the effects of different payment systems in achieving these objectives. Target payments are a payment system which remunerate professionals only if they provide a minimum level of care.

Objectives

To evaluate the impact of target payments on the professional practice of primary care physicians (PCPs) and health care outcomes.

Search methods

We searched the Cochrane Effective Practice and Organisation of Care Group specialised register; the Cochrane Controlled Trials Register; MEDLINE (1966 to October 1997); BIDS EMBASE (1980 to October 1997); BIDS ISI (1981 to October 1997); EconLit (1969 to October 1997); HealthStar (1975 to October 1997) Helmis (1984 to October 1997); health economics discussion paper series of the Universities of York, Aberdeen, Sheffield, Bristol, Brunel, and McMaster; Swedish Institute of Health Economics; RAND corporation; and reference lists of articles.

Selection criteria

Randomised trials, controlled before and after studies and interrupted time series analyses of interventions comparing the impact of target payments to primary care professionals with alternative methods of payment, on patient outcomes, health services utilisation, health care costs, equity of care, and PCP satisfaction with working environment.

Data collection and analysis

Two reviewers independently extracted data and assessed study quality.

Main results

Two studies were included involving 149 practices. The use of target payments in the remuneration of PCPs was associated with improvements in immunisation rates, but the increase was statistically significant in only one of the two studies.

Authors' conclusions

The evidence from the studies identified in this review is not of sufficient quality or power to obtain a clear answer to the question as to whether target payment remuneration provides a method of improving primary health care. Additional efforts should be directed in evaluating changes in physicians' remuneration systems. Although it would not be difficult to design a randomised controlled trial to evaluate the impact of such payment systems, it would be difficult politically to conduct such trials.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Some evidence to suggest that target payments to physicians increase immunisation rates

This review looked at the effects of target payments on the behaviour of primary care physicians (e.g. general practitioners and family physicians). Under a target payments system a lump sum is paid to physicians who provide a certain quantity or level of care. Two studies assessed the impact of target payments on immunisation rates. There was some evidence that target payments resulted in an increase in immunisations by primary care physicians. However there was insufficient evidence to provide a clear answer as to whether target payments were an effective method of improving quality of care.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

初級照護實施目標支付制度:對專家做法及健康照護結果的影響

透過支付何種項目給醫師的方法也許會影響他們專家的做法。雖然支付系統也許是用來達成政策目標(如促進照護品質，維持成本及納入低服務地區)，但有關不同支付系統對於達成這些目標的效果卻了解不多。目標支付制度是一種支付系統，只在專家提供最低限度的照護時給予專家報酬。

目標

評估目標支付制度對於初級照護醫師(primary care physicians (PCPs))的專家做法及健康照護結果的影響。

搜尋策略

我們檢索Cochrane Effective Practice and Organisation of Care Group的專科登記資料庫；Cochrane Controlled Trials Register；MEDLINE (1966至1997年10月)；BIDS EMBASE (1980至1997年10月)；BIDS ISI (1981至1997年10月)；EconLit (1969至1997年10月)；HealthStar (1975至1997年10月) Helmis (1984至1997年10月)；Universities of York，Aberdeen，Sheffield，Bristol，Brunel及McMaster健康經濟學系列的討論文章；Swedish Institute of Health Economics; RAND公司；及文章的參考文獻。

選擇標準

比較目標支付制度對照其他支付方法對初級照護專家，病患結果，健康服務利用，健康照護成本，照護公平性，及初級照護醫師對工作環境滿意度等的影響之隨機臨床試驗，前後對照研究及間斷時間序列分析。

資料收集與分析

兩名審查者分別摘錄資料及評估研究品質。

主要結論

納入兩篇研究共收集了149名受試者。使用目標支付制度給予初級照護醫師報酬與促進免疫接種率有關，但僅一篇研究有達統計顯著增加。

作者結論

有關目標支付制度的報酬是否可以提供一種促進初級健康照護的方法，這篇回顧的研究證據並沒有足夠的品質或檢定力以獲得問題的明確答案。應多加致力於直接評估改變醫師的報酬系統。雖然設計一個評估這種支付系統的影響的隨機對照試驗不是很困難，但政策上難以建立這種試驗。

翻譯人

本摘要由高雄榮民總醫院金沁琳翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

有些證據認為目標支付制度會使醫師增加免疫接種率。這篇回顧觀察目標支付制度對於初級照護醫師(如一般開業醫或家庭醫師)行為的影響。在目標支付制度下，給予提供特定數量或照護水準的醫師一筆金額。兩篇研究評估目標支付制度對於免疫接種率的影響。有一些證據指出目標支付制度會使初級照護醫師增加免疫接種。然而關於目標支付制度是否是一種改善照護品質的有效方法，則無充分證據提供明確的答案。

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