Kommentar zu "Can payers use prices to improve quality? Evidence from English hospitals"

Literature Review 2017 10 Pages

Economy - Health Economics


Table of content

1. Summary of the Journal Article

2. Discussion of results

3. Discussion of the relevance of the problem identified

4. Is there anything to learn about for the German healthcare system?

5. References

1. Summary of the Journal Article

The “Best Practice Tariff”-program (BPT) is one of many pay-for-performance models which have been introduced in the health system of the United Kingdom (UK). The first one was the "Quality and Outcome Framework" (QOF) followed by "Advancing Quality" (AQ), Commissioning for Quality and Innovation (CQUIN), "Non-Payment Policies" (NPP) until 2010, where the BPT has started.1 First, it was used in four indicators: cataract, gall bladder removal, stroke and fragility hip fracture. Now, the BPT includes 50 procedures in the UK. The payment of the service providers is based on the principles of the best treatment and therefore it does not depend on the average costs and can thus be higher or lower than the previously determined flat rate. The BPT can consequently be regarded as a punishment for hospitals that are not working compliant.2 The purpose of the BPT is to change treatments from inpatient cases to outpatient daycases, to reduce the number of appointments for patients and to increase the quality of the results.3 In the article by Allen et al. from 2016, the impact of the BPT on one of the four primary treatment cases, cholecystectomy, was investigated. Cholecystectomy is an operation in which the gallbladder is removed under general anesthesia, either laparoscopically or as an open surgery. Laparoscopic cholecystectomy is classified as an intervention in the UK, which can be performed as a daycase event. The aim of the BPT for cholecystectomy was to motivate the hospitals to carry out the procedure more frequently as a daycase event without losing quality. To investigate the effects of BPT, Allen et al. analyzed data from the Hospital Episodes Statistics from 1 December 2007 (before BPT) to 31 March 2011 (after introducing BPT). For this research, the cholecystectomy was compared with a control group consisting out of procedures from other medical fields (for example ear, nose, neck). After the evaluation Allen et al. came to the conclusion that a potential effect of the policy is visible.4 The concrete investigation results are discussed in Chapter 2.

2. Discussion of results

In order to be able to compare the results of the two groups, the following factors were examined over the fixed period: the daycase proportion, the planned daycase rate, the reversion rate, the proportion of patients needing a stay longer than one night, the readmission rate, the laparoscopic proportion, and the median waiting time. Allen et al. came to the conclusion that the BPT has achieved its expected effects. The daycase proportion rose by 5.8 percentage points, the planned daycase rate increased by 11.1 percentage points. On the quality there were no perverse effects reported. In the announcement of the BPT policy, the reversion rate fell by 4 per 1000 and later after the introduction once again by 0.7 per 1000. While the proportion of patients needing a stay longer than one night showed a decrease by a total of 4.4 percentage points , no statistically significant results could be observed at the death and readmission rate. Nevertheless, it was also established that the laparoscopic proportion increased in two out of three specialties. The observed effects support the hypothesis that the BPT has reached its expected goal. The changes in the payment forced the hospitals to make changes in their procedures during the patient treatment. These changes did not lead to rough deterioration in patient care.5 Due to the higher daycase rate, there were higher waiting times for patients, which could be mentioned as one negative aspect.6

However, it is important to note that only the effects of the BPT on cholecystectomy were analyzed in this study. Other studies in the field of fragility hip fracture also showed positive results by introducing the BPT. The mortality rate decreased moderately by 0.7% and patients were given to the surgeon earlier than it had previously been the case. However, in the first year after the introduction of the BPT, there was no significant positive impact on the process and outcome indicators in the Stroke segment.7 Consequently, there are different results in evaluating the effect of the BPT.

Furthermore, it must be noted that the results only represent short-term effects. Further research will be necessary for the evaluation of the long-term effects.8 Overall, it can be said that Allen et al. were able to submit statistically significant and plausible results from their investigation highlighting the positive short-term aspects of BPT.

3. Discussion of the relevance of the problem identified

The BPT is part of the ever-growing pool of pay-for-performance models. Pay for performance is a direct financial incentive and non-intangible incentive.9 The models are part of the alternative payment models (APM) and are intended to replace fee-for-service systems (FFS) as they reward the treatment volume rather than the quality of the treatment.10 Especially in the field of health care, the quality of the treatment results has become the main focus in recent years, which is one reason why the introduction of pay-for-performance models has been controversially discussed in many countries for a long time. In 2005, as a result of the increasing importance of quality, minimum quantities were set for some operations in Germany. Hospitals, which do not reach a specified number of procedures during certain medical interventions, may no longer provide them in their performance catalog. The underlying idea of this measure was that the frequent implementation of a procedure emerges through more experience in a higher quality of results. For example, the operating unit can react better to complications due to their experiences. Transparency has also increased in the healthcare sector in recent years. On the one hand hospitals publish quality reports to inform patients, on the other hand for image reasons. Pay-for-performance programs also apply here. They try to make the treatment process transparent and underline the quality aspect of the treatment. The performed procedures occur according to evidence-based measures and should be regarded as clinically correct.11

The prerequisite for the implementation of these programs is, that the treatment guidelines are constantly revised, only in this way it can be guaranteed that the latest medical status is always given.12 A further not negligible aspect is the attempt to allow a cost reduction by the increased quality in the therapy results.


1 Meacock et al. (2014), p.2

2 Gershlick (2016), p.5 ff.

3 Meacock et al. (2014), p.6

4 Allen et al. (2016), p.58 ff.

5 Allen et al. (2016), p.65 ff.

6 Meacock et al. (2014), p.10

7 Meacock et al. (2014), p.10

8 Allen et al. (2016), p.67

9 Schrappe and Gültekin (2011), p.166

10 Kondo et al. (2016), p.61

11 Kondo et al. (2016), p.66

12 Emmert (2008), p.392 f.


ISBN (eBook)
Catalog Number
Institution / College
University of Bayreuth
Best Practice Tariff UK United Kingdom quality pay for performance hospital



Title: Kommentar zu "Can payers use prices to improve quality? Evidence from English hospitals"