Designing and Implementing Health Care Provider Payment Systems: How-To Manuals

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"Strategic purchasing of health services involves a continuous search for the best ways to maximize health system performance by deciding which interventions should be purchased, from whom these should be purchased, and how to pay for them. In such an arrangement, the passive cashier is replaced by an intelligent purchaser that can focus scarce resources on existing and emerging priorities rather than continuing entrenched historical spending patterns.

Having experimented with different ways of paying providers of health care services, countries increasingly want to know not only what to do when paying providers, but also how to do it, particularly how to design, manage, and implement the transition from current to reformed systems. 'Designing and Implementing Health Care Provider Payment Systems: How-To Manuals' addresses this need.

The book has chapters on three of the most effective provider payment systems: primary care per capita (capitation) payment, case-based hospital payment, and hospital global budgets. It also includes a primer on a second policy lever used by purchasers, namely, contracting. This primer can be especially useful with one provider payment method: hospital global budgets. The volume's final chapter provides an outline for designing, launching, and running a health management information system, as well as the necessary infrastructure for strategic purchasing."

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Product Details

  • ISBN-13: 9780821378151
  • Publisher: World Bank Publications
  • Publication date: 5/14/2009
  • Pages: 344
  • Product dimensions: 6.90 (w) x 9.90 (h) x 0.80 (d)

Table of Contents

Preface xi

Acknowledgments xiii

List of Contributors xv

Abbreviations xviii

Glossary xix

Overview: What, How, and Who: An Introduction to Provider Payment Systems 1

Aims and Readership of This Volume 1

Provider Payment Systems and Methods: An Overview 3

Main Characteristics of Provider Payment Methods 12

The Way Forward 19

Organization of This Volume 20

Notes 24

References 24

1 Primary Health Care Per Capita Payment Systems 27

Overview of PHC Provider Payment Systems 27

Defining the Health Policy Context 27

Methodology for Developing a Per Capita PHC Payment System 33

Defining a PHC Package of Services 35

Setting the PHC Pool and Calculating the Base Per Capita Rate 37

Calculating Risk Adjustment Coefficients 40

Developing an Enrollment Database 52

Calculating Each Provider's Per Capita Budget 61

Designing a Finance and Management System 62

Designing a Monitoring and Quality Assurance System 75

Expanding the Base Per Capita Rate and Package of Services 87

Implementation Issues 89

The Link between PHC Per Capita Payment and the Health System Axes: Experience from Four Central Asian Republics 97

Note 120

References 120

2 Case-Based Hospital Payment Systems 125

Overview of Case-Based Hospital Payment Systems 125

Defining Case Grouping Criteria 134

Completing Cost-Accounting Analysis 148

Calculating Case Group Weights 159

Calculating the Base Rate 161

Designing an Information and Billing System 170

Refining Case Grouping 190

Implementation Issues 192

Case Studies from Kazakhstan and the Kyrgyz Republic 196

Notes 211

References 212

3 Hospital Global Budgeting 215

Overview 215

Setting theHospital Global Budget 218

Performance Incentives 229

Nonbudget Funding 232

An Overview of Costing 241

Managing the New Global Budget 248

Annual Adjustments 248

References 253

4 A Primer on Contracting 255

Introduction 255

Which Contract? 256

Volumes 257

Which Contract When? 259

Consortia 261

Duration of Contract 262

Note 262

5 Health Management Information Systems: Linking Purchasers and Providers 263

Background 263

Implementing Appropriate Provider Systems 268

Implementing Appropriate Purchaser Systems 283

Implementing an Appropriate Link between Purchaser and Provider Systems 291

Concluding Remarks 297

Annex 5.1: A Primer on Health Management Information Systems 300

Notes 304

References 304

Index 307


Box 1 Incentives 2

Box 1.1 Balance of Decision Rights in Costa Rica 33

Box 1.2 Top-Down Estimation of the PHC Pool as a Health Policy Tool 39

Box 1.3 Open Enrollment in Zhezkazgan, Kazakhstan 56

Box 1.4 Budget Overruns and the Unadjusted Base Per Capita Rate 63

Box 1.5 Budget Neutrality and a Per Capita Rate Adjusted Using Age/Sex Adjustors 64

Box 1.6 Budget Neutrality and a Per Capita Rate Adjusted Using Both Geographic and Age/Sex Adjustors 65

Box 1.7 Introductory Training for Finance Managers in Uzbekistan 68

Box 1.8 Basic Health Management for General Practitioners in Uzbekistan 70

Box 1.9 Issues and Solutions in a Fully Automated System in the Kyrgyz Republic 74

Box 1.10 Benchmarking, Not Targets, in Karaganda, Kazakhstan 84

Box 1.11 PHC Monitoring System in Karaganda, Kazakhstan 86

Box 1.12 Provider Satisfaction 93

Box 1.13 Results of Increased Provider Autonomy in Karaganda, Kazakhstan 96

Box 1.14 Karaganda Achievements 110

Box 2.1 Possible Adjustment Coefficients to the Payment Per Case Formula 132

Box 2.2 Initial Case Groups and Weights in the Kyrgyz Republic 135

Box 2.3 Major Diagnostic Categories in the Australian Refined Diagnosis-Related Groups Classification 141

Box 2.4 Serial Example: Calculating Average Cost per Case 144

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