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Keywords:

  • Payment by results;
  • smoking cessation;
  • Stop-Smoking Services

Maynard et al. warn of the pitfalls in attempting to fund drug misuse treatment services on a ‘payment by results’ (PBR) basis [1]. They note that the definition and measurement of success is complex and challenging. In the field of smoking cessation support life is much simpler, but adopting a PBR system is still potentially fraught with problems.

Before setting out the specific problems it is important to note that the financial system within which PBR operates itself presents considerable challenges. The most efficient health-care system in principle is one in which there is an integrated service funded out of general taxation where (i) a budget is set based on an analysis of the need and what can be afforded, (ii) priorities are established for specific areas of service provision based on evidence-based cost-effectiveness calculations on the part of experts and value judgements on the part of democratically accountable representatives of the citizenry, (iii) there is transparency and individual and collective accountability for effective running of services at every level and (iv) patients act responsibly in the demands they place on the services. The UK's National Health System had many of these features until the 1980s, when an ‘internal market’ was created, and it now runs as a quasi-market with ‘purchasers/commissioners’ and ‘providers’. The rationale for this was that only by creating a competitive market could the system be made efficient. The alternative option of increasing transparency and accountability within an integrated system was not pursued.

The quasi-market option adds considerable costs in terms of administration for commissioning and charging for services. It also fragments service provision and engenders distrust and secrecy between service providers and it does something else that leads almost inevitably to PBR: it drives down quality of service to the maximum extent that a service provider believes it can get away with. When private companies become involved as providers the profit motive, or maximizing directors' remuneration, acts as a powerful driving force. To counter this, it becomes essential either to enforce standards of care or to try to maintain these through PBR. Until now, the approach has been to try to enforce standards of care. However, this is expensive, open to considerable subjectivity and in practice extremely difficult to achieve. PBR seems to offer a more efficient method because the provider only gets paid for successes and that in theory should maintain or enhance standards of care. In theory . . . 

Considering the case of Stop-Smoking Services, one can see how this would not necessarily work in practice. First, a certain proportion of smokers who try to stop would have managed to do so by themselves, so not every successful quitter from a service can be attributed to that service. Ignoring this incentivizes providers to spend as little as possible in actually delivering support and simply capitalize on the fact that a proportion of smokers will manage to quit anyway. Secondly, maximizing the PBR return incentivizes providers to ‘cherry-pick’ easy cases. In the case of smoking, the ‘ideal’ client is a middle-aged or elderly man from a professional background smoking relatively few cigarettes per day with no substance misuse or mental health problems [2]. Thirdly, it discourages use of relatively expensive treatment options that produce somewhat better results but not at a rate fully commensurate with the cost. One might imagine that this is reasonable, because it maximizes cost-efficiency, but when one considers that all smoking cessation interventions are extremely cost-effective and affordable [3], condemning a predicable number of smokers to death from a smoking-related disease by denying them a treatment option that is not maximally cost-efficient is unethical. Fourthly, it incentivizes over-claiming of successes that can vary from ‘game-playing’ to outright fraud. If we take 12 weeks of continuous abstinence as the main outcome, there is no way of ensuring that smokers' are truthful. Even if the smokers are truthful, there is clearly an incentive on the practitioner to report success. This need not involve an outright lie; the practitioner need only ask the question in a way that maximizes the chances of gaining the desired response; and even if the practitioner is truthful the provider may ‘adjust’ the figures. Moreover, an easy of way gaining a high success rate is simply to find smokers who have already given up and take credit for their success.

All these problems can be overcome, but unless they are all addressed PBR will prove costly and ineffective. Ethical providers will be driven out of business by unethical ones or forced to adopt the same unethical practices. The recipe for avoiding these pitfalls is as follows.

  • 1
    Only pay for successes that are above a threshold that represents the estimated success rate for the population of smokers concerned without support. For the general population of smokers in the United Kingdom and United States we estimate that some 25% would succeed with medication alone for 4 weeks [4]. Thus, if a provider sees 1000 smokers and encourages 350 to quit, only pay for 100 treatment successes. Vary the threshold figure for a provider as a function of the ‘difficulty’ of the client base using regression equations that predict the average untreated success rate for that population.
  • 2
    Vary the tariff or payment according to the average cost of generating a success for different groups. This may need to take into account the costs of attracting smokers into the service as well as the cost of treatment. This can be achieved using regression equations from existing data.
  • 3
    Only commission providers who are ‘accredited’ and set clear criteria for accreditation which involves ensuring that they: (i) offer all evidence-based treatment options including those that are more expensive but more effective, (ii) adopt recommended selection, training and certification procedures for their staff, (iii) ensure that their staff are supervised appropriately and undergo regular continuing professional development, (iv) follow evidence-based treatment guidelines for delivery of behavioural support, (v) adopt a rigorous procedure for assessing abstinence, including use of a standard question and biochemical verification and (vi) have their claimed quitters checked by an independent audit which ensures that they set a quit date with the service and did indeed quit.

These safeguards will not address the wider problem of a quasi-market, but unless all of them are in place PBR will lead to degradation of stop smoking support, huge sums of money wasted and many lives lost.

Declaration of interest

  1. Top of page
  2. Declaration of interest
  3. References

R.W. is a co-director of the NHS Centre for Smoking Cessation and Training, an organization funded by the English Department of Health to establish and promote best practice within the English Stop-Smoking Services. He also consults to a number of manufacturers of smoking cessation medications, including Pfizer, GSK and J&J, and is a trustee of the stop-smoking charity, QUIT.

References

  1. Top of page
  2. Declaration of interest
  3. References