Sandrine Boucher

PAYMENT FOR PERFORMANCE IN
FRENCH ACUTE CARE HOSPITALS
Oslo, June 2013

The financing of French acute care hospitals
is for a large part based on activity
Activity based
payment
ONDAM 2013*
for hospitals
ODMCO
46.7
billion €
MIGAC
8.6
billion €
Payment not
based on activity
56.6 billion Euros
in 2013
(*) national health care insurance projected expenditure for 2012
85% of the financing of French acute
care hospitals is based on activity
In combination with budget for
specific activities like :
Research and education,
Public healthcare missions e.g.
palliative care, emergency…
Contracts between regulatory authority
and hospitals e.g. financial aid to
develop a new activity, to support an
activity showing a deficit…
National health care insurance is the
main “payer” for hospitals (80%)
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What are the advantages and disadvantages
of a fee-for-service model?
Activity based payment
(called T2A in France)
Pros
•More fairness for health providers
•More independence for hospital
managers
•Better use of resources by rewarding
efficiency
•More transparency in the payment
model
Cons
• Inflationary, rise of health care costs
by rewarding overutilization (volume
or cost)
• Bias in choice of patient for
profitability goal
• Excessive decrease in length of stays
• Costs of collect and audit of
information
• Cooperation discourage
• No incentive to increase the quality
level
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Government goal is to increase quality and to
reduce costs : how do they intend to do it ?
Different levels of pressure on hospitals
Accreditation
Public
diffusion
Quality Label,
certification
In 2013
Financial
incentive
2003
Definition of quality
measures
First certifications by HaS*
2004 Testing of measures
2005
2006
2007
2008
In France
Implementation of
nosocomial infection
measures
Implementation of
clinical practice
process measures
(*) national health autority
2013
Public reporting of
22 quality indicators
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After 6 years of T2A, French government has
decided to test a performance based payment
2003 Global budget
2004 10% T2A
2005 25% T2A
2006 35% T2A
2007 50% T2A
2008 100% T2A
2009
2010 Performance based
2011
payment discussions
2012 Performance based
2013
payment announcement
2014 First performance
based payments
Up to now, some quality based payment has
existed, based on volume and not on
performance e.g. :
Pathology “announcement” package
In 2012, 2 years after the first discussions with
professionals on the subject, the first test of
performance based payment was announced in
France for acute care hospitals
In 2014, some French acute care hospitals will
begin to be paid for performance
The French performance based payment
rewards better care quality
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Hospitals responded very favorably to the call
for volunteers for this first test
A call for volunteers was sent to more than 1300 French
acute care hospitals in July 2012
Initially the French government aimed at 100 hospitals for the
test
450 hospitals volunteered
French government decided to enlarge the number of
hospitals in the test to more than 200
Two reasons for this success :
No sanctions, only rewards
No additional workload in case of participation
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The French government is now defining the
payment mechanism
At what
frequency ?
How much ?
• Financial incentives
or penalties ?
• Which weight in the
global financing ?
• Fixed or variable
amount ?
Mechanism What ?
How ?
• Level of selectivity ?
• Readability versus
equity ?
• Objects of the
payment?
• Measures to be
used?
• Relative weights of
different
components ?
What do we know about
the future model ?
• 15 measures included in the
model
• No sanctions, only rewards
• One score for attainment and
one score for improvement,
when it is possible
• 12 million Euros allocated for
the test
• Relative weight of components ?
Exchange model ? (to be defined)
The French model is inspired by the American P4P
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Will the program succeed in improving value
in health care ?
Is the planned
budget sufficient
to change
behaviors ?
Is the model too
complex to be
managed ?
Are the available
indicators
adapted to a payfor-performance
payment ?
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The planned budget is very small compare
to what is expected
Description of the projected
model
Only 12 million Euros for the
test
No sanction, only reward
A maximum 0,5% of activity
resources per hospital (not less
than 50 000€ and not more than 500
000€)
► If each hospital earn 100% of the
maximum amount, government
should distribute more than 45
million Euros
Commentary
The average payment will be less
than 0.2% of the activity resources
With this budget and without
sanction, they will be :
either a small number of hospitals that
will benefit from financing
or a very small amount for larger
number of hospitals…
► Will this be sufficient to change
behaviors?
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Does France have indicators suited to a
quality based payment ?
Pros
• There are good measures
related to care organization
(certification)
• All acute care hospitals have
some standardized process-ofcare
measures in common
• Hospitals publish a part of
these measures and are ranked
Cons
•For the majority of diagnoses,
there is no specific measure
•There is no measure of :
• Outcomes, for example
nothing on patient mortality,
on hospital-acquired
infections, on readmissions
• Patient satisfaction
• Patient health
France improves its quality measures every year (patient
satisfaction, mortality measure…)
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What about the mechanism ?
To encourage improvement in quality level …
… the mechanism must be easily understood by a
hospital manager i.e. a “user friendly” tool
Unfortunately, a high number of indicators are
included in the test
15 measures
Many in two parts, an improvement score and an attainment
score
All available indicators included in the model.
No focus on priority indicator.
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French model versus other P4P payments
Negative
substitution
Cost of
implementation
REGULAR
CRITICISMS
ON P4P
PAYMENTS
Patient access
issues
Complex data
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Conclusion
The quality based payment is one response to one of
the main criticisms of the activity based payment.
Unfortunately in the French test, in my opinion,
the planned budget seems low to really change behaviors,
the model is based on available indicators and France could
improve its quality measures in health care,
the mechanism seems very complicated to be efficiently
monitored by an hospital.
but….
FOCUS ON “QUALITY”
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