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Incentives in Healthcare Payment Systems

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Health services providers receive payments mostly from private or public insurers rather than patients. Provider incentive problems arise because an insurer misses information about the provider and patients, and has imperfect control over the provider’s treatment, quality, and cost decisions. Albert Ma discusses incentives in healthcare payment services.

Image courtesy of interviewee. July 24, 2024

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This video discusses the intricacies of payment incentives in the U.S. healthcare system, particularly focusing on the roles of three primary parties: consumers (patients), providers (medical personnel), and payers (insurance companies, government, or employers). The healthcare sector accounts for a significant portion of the U.S. GDP, making the study of payment mechanisms vital.

Initially, the text highlights the traditional fee-for-service model, where providers are reimbursed for actual costs incurred, creating a potential incentive for overutilization of services, which can contribute to rising healthcare costs. In contrast, the prospective payment system sets fixed prices for specific episodes of care, irrespective of the resources used. This video model encourages providers to be more efficient by internalizing costs.

The discussion delves into the internalization principle, which suggests that for a provider to align their actions with payer goals, they must be incentivized to internalize both costs and benefits of their service delivery. This video principle is illustrated through examples, such as incentivizing students through exams to ensure consistent studying over the semester.

This video also addresses potential issues with the prospective payment model, namely "dumping," where providers might avoid high-cost patients, and "cream skimming," where they attract low-cost patients, undermining the effectiveness of the payment system. Additionally, the conversation extends to nuances such as blending fee-for-service with prospective payment mechanisms to manage provider behavior effectively.

Lastly, the text notes that by developing more sophisticated payment models that account for organizational behavior—like paying for a group of providers instead of individual practitioners—the healthcare system can improve the quality of care while managing costs. It concludes by emphasizing the ongoing evolution and complexity of healthcare payment literature and its impact on provider behaviors and healthcare outcomes.

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Healthcare is a very important part of any society,

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and it's particularly important in the US

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because it occupies up to 20% of GTP.

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There are various ways that we can think about healthcare

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and, today I'm just going to concentrate on

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this element called payment incentives.

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There are other issues to think about, like insurance

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and so on, but they will be left on another location.

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So why are payment incentive at all relevant?

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The basic issue is that there are sort

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of three parties in this, in this scenario.

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They're the consumers, they're the providers,

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and then they're the payers.

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It is like they interact. Consumers are patients.

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They want some services.

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Providers are medical personnel and facilities

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and healthcare professionals.

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And then the pay is a government, employers,

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insurance companies, public or private.

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It depends on various different countries.

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Basically, consumers demand

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and receive services from providers.

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The insurance will shield consumers from receiving, will

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shield consumers from part of the surface expenses.

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That's the whole point of health insurance

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because illness carries some financial risk.

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And the insurance part says

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that when you seek medical treatment, both

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or part of the medical expenses will be paid for

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by the insurance company.

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Now this creates an obvious issue, which I'll come

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to in just one moment.

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Uh, who pays the bill?

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If consumers don't pay, the payers would have,

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would have to pay.

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So how,

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providers paid would

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therefore determine their behavior?

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If the payer can make providers be

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efficient so much, the better.

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And what are the ways to make them efficient?

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Um, in the old days, like 50 years ago,

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60 years ago is Medicare in the US

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and many other countries use something called fee

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for service or cost reimbursement.

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Whatever cost a provider incurs to surface consumers,

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the payer will just reimburse the expenses.

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Uh, of course this may often include a profit margin.

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So the profit margin is, it can be an issue

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because the profit margin then create an incentive problems.

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There will be more services provided and maybe qualities

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Can be made inefficiently high

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to attract services demanded by, demanded by consumers.

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The cost reimbursement fee for service has been regarded

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as a major reason for the high cost in the us

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That's one of course base payment mechanism.

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And there's an obvious incentive issue, then

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a popular, and now very,

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very common payment mechanism is called prospective

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or fixed price mechanism.

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It works like this. It works in two steps.

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First, we sort of define an episode of care.

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Let's say a patient gets into a hospital,

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eventually the patient gets discharged,

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and let's say this is a pneumonia episode.

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At the end of the episode, appoint discharge at

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that primary diagnosis called pneumonia will be associated

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with the patient and the discharge.

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Now this category

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of pneumonia will be associated with a price.

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This price will be the payment

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that the payer makes to the provider.

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It is a fixed price mechanism.

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No matter what kind of resources the provider has incurred.

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No matter how many days the patient stays in the hospital,

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it will be the same price.

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And, and it is very different from cost reimbursement.

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Cost reimbursement says, well, if you stay longer,

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we'll pay you more, stay shorter,

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we'll pay you less fixed price.

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Prospective payment says no matter what kind

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of resources you use,

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provided that you know the the provider, the hospital has

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to treat you in a satisfactory way.

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Um, the payment will remains the same.

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So what does it aim to achieve?

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Well, think about the following scenario.

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The two things that the provider does.

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The provider is gonna make quality decision

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and it's gonna make cost decisions.

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The quality decision can be associated with,

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nursing care, the, facilities, tests

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and any other things that, consumer,

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the patient may enjoy raising qualities will

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be sort of good for consumers and will raise demand,

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and consumers can be happier with higher quality.

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But of course, qualities can be very costly

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when costs are high,

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the hospital doesn't get paid more.

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So there is in some sense a way an incentive for the

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provider to reduce costs.

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Reduce costs, reduction of costs can happen in many ways.

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Um, finding the right treatment,

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finding the appropriate treatment, and even the organization

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Of the hospital of the facility

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can sometimes affect costs.

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Okay, so these are the thing about this as the two decisions

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that a provider makes

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and, the cost reimbursement system that we,

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I talk about just, you know, few minutes ago, the fee

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for service says that cost will always be paid for,

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even if I reduce cost, my payment

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would not get me more profit

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because it would just be reducing the reimbursement for me.

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Okay? Now,

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prospective payment doesn't work in the same way.

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Okay? And then,

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and let me now tie tie it to this, the sort

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of the economic principles involved in all this,

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and I call this the internalization principle.

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It applies in a very general setup,

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is not limited to healthcare.

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It says the following.

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If A wants B to do something

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that A desires A wants B to do something,

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A cannot control B'S behavior A cannot co B's action, then

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B must be made to share a's preferences.

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In other words, B must be made

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to internalize ace benefits and costs.

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I'll give you a very simple, since we are at a university,

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a very simple example,

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why do we think we have midterms and final?

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Why not have just the final exam?

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You see, once we have a midterm, that will be an incentive

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for students to study during the midterm

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during the first half of the semester.

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And the final, of course, would be another way

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to motivate students to study during,

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during the second half of the semester.

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So if we want students to be studying

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throughout the semester, these two exams will be needed.

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So I as a professor warned my student to study gradually

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and consistently, and

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therefore I set up these two exams so that my preferences

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for their learning behavior will be more in, in line

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with their incentive to perform well in the exam.

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Now, of course, in quality choices to the satisfaction

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of the, of the payer, the provider makes two choices.

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Um, so think about the following, another sort

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of principle, one

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and a half, the internalization principle, right?

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I, I want the payer to think of a way

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to internalize this cost

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and quality incentives, motivation,

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perspective by the provider.

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Okay? Now you think about that.

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Two things that I want to do.

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I need them to study first half

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and I want them to study second half of the semester.

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I need two exams. One exam isn't quite good enough, right?

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So you think about cost and quality choices

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and cost in quality incentive.

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You naturally think, well, we need two instruments.

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One needs an instrument to motivate cost incentives.

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One needs, an instrument to motivate,

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quality incentives.

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Now, what is the beauty of the prospective payment?

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What does the pro prospective payment say?

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Is the provider is responsible for cost

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no matter what the cost is, the payment from the payer

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to the provider is constant.

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In other words, it internalizes cost, so to speak.

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The provider under this payment mechanism has already

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one instrument to align the cost incentives.

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So what are we left behind with?

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We are left behind with the second instrument.

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The price, higher price would

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therefore encourage higher quality, lower price can,

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encourage or discourage higher quality.

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Okay, let's say you have this patient

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who has pneumonia being admitted to the hospital, right?

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So how many days to stay?

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Uh, okay, well, the hospital has to bear the cost.

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You cannot just send away the patient when

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the patient is very sick.

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Uh, the quality of care now depends on what, depends on

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how much the hospital is paid.

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If this price upon this charge is high,

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then we have an incentive to provide, would've an incentive

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to make the patient happier.

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So the price can be adjusted to align some incentive.

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The price can be made, can be set.

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So the provider to internalizes the benefit.

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So that's the internalization principle.

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The provider wants, the, the,

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the payer wants a provider to have

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efficient cost and quality decisions.

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And the way to do it is to ask the provider

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to internalize the cost and benefit the desirable part

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and the, and the costly part of the cost

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and quality incentives.

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We have one instrument because the prospective

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payment is a single price.

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However, the beauty of prospective payment is

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that cost is already internalized.

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By definition, the provider has to bear the cost.

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So we have, we have full efficiency in

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this, in this scenario.

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Now, it also brings out the issue about fee for service.

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Fee for service would never induce efficiency simply

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because cost is always reimbursed.

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That part of the sort of the equation

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of the incentive is never internal

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provided, does not internalize.

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Alright? So that's the sort of the literature

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I I sort of started, about 30 years ago is, one

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of the first papers to recognize that,

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providers behavior can be multifaceted.

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They have many things that they can do,

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some concern causing some concern, quality

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and different payment mechanism is steering them towards

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different kinds of behavior, right?

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It's simple model, but we always start with simple model

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because we can derive insights

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and then we can continue to work on the same principle,

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but relaxing various, restrictions.

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So what is the catch?

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Uh, way back when people already spotted

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some issues with prospective payment.

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Um, the prospective payment suffers from some

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well-known problems.

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It's called dumping and cream skiing. So what is dumping?

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Dumping refers to the idea that

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to make money a provider can simply turn away very

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expensive patients.

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It's quite illegal in many countries, in most countries.

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Uh, but it doesn't stop people, providers from hinting,

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for example, that your case may,

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your maybe better off being treated elsewhere.

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Uh, this is for your own benefit and this

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and some persuasion can drive some expensive patients

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to other providers, right?

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This is called dumping

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and cream skimming, refers to higher

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quality to attract more attractive to, to,

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to, to get more, profitable patients.

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So this is the idea.

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Well, in, in the case of services,

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maybe we are going to have very good pre-op services

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before the operation, before, the actual procedure.

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We, we will advise you on what to do, what not to do, and

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therefore this will enhance your experience.

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Although, you know, surgery may never be a good experience,

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it is going to be sort of a, a more welcoming strategy.

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Okay? So what is the catch?

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What what is the problem with prospective payment?

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You ask consumers, you ask providers

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to bear the full cost,

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but they don't have to bear the full cost.

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If they understand that they can turn away some very

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expensive or costly patients.

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So this idea is called dumping and cream ischemic, okay?

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Cost variations

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therefore may limit the power

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of prospective payment selection incentive.

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The so-called dumping

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and cream skimming,

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may be avoided by fee for surface.

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So I'm not going to argue that fee

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for surface is completely useless in the case of,

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cost variation.

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Um, then fever surface can eliminate some sort

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of undesirable dumping or cream scheme.

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It's still a fairly simpl simplistic scenario.

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But notice what I've done.

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I have started with the internalization principle

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and then I've started counting.

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I've got a mechanism, I've got payment method

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to incentivize a provider,

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and I've listed two things that the provider is doing,

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like cost and quality.

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I have successfully introduced more

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and more actions available to the provider,

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selecting patients, getting the good risk,

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getting the less expensive patients.

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Uh, so now I have sort of three problems.

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And now prospective payment has only one single instrument,

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although it does force the provider

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to internalized costs, right?

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As you gradually make the situation more

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and more complicated, if you allow, the provider

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to have more power over its environment,

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over its profit maximization attempt, you're gonna see

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that none of the mechanism

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that we have ever considered is sort

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of completely foolproof.

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There will be some sort of trade off

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the extent literature has sort of documented this kind

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of trade off in the past 30 years

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or so, we have expanded this literature into

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various scenarios.

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Uh, the extent literature is about making the analysis more

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realistic and more practical.

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First, I was just talking about providers

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as if they were just trying to maximize their profit.

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In many circumstances, this may not really be

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the correct assumption.

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They may be a little bit altruistic.

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They may love their patients to some extent

16:50.785 --> 16:52.635
they care about consumer's wellbeing.

16:53.415 --> 16:58.315
Now that element alone is not that hard to to handle.

16:59.445 --> 17:02.665
Uh, if you love your patients 50%, well, okay, I'm, I'm,

17:02.665 --> 17:05.105
I'm going to ask you to bear 50% of the cost.

17:05.615 --> 17:08.905
I'll reimburse you 50% of the cost, but not everything.

17:10.085 --> 17:11.305
The price will be adjusted

17:11.305 --> 17:14.385
because I know that I don't need a lot of incentive for you

17:14.385 --> 17:16.235
to provide for it, right?

17:16.255 --> 17:18.595
So this mixing fee for service

17:19.215 --> 17:22.995
and prospective payment together is a very effective way

17:23.695 --> 17:27.915
to account for, so-called provider heterogeneity.

17:29.325 --> 17:31.465
And that has been done over the years,

17:31.525 --> 17:32.585
in, in various papers.

17:34.885 --> 17:38.455
Then in more recent years, we have expanded sort of

17:39.075 --> 17:42.685
discussions about, for example, pay for performance.

17:43.455 --> 17:46.115
Uh, we are not just paying for the discharge.

17:46.535 --> 17:50.285
We like to assess how well the patient is, is feeling

17:50.615 --> 17:53.765
after a certain amount of time period.

17:54.615 --> 17:57.665
Is there any way that we can assess,

17:57.895 --> 17:59.705
performance by the provider?

17:59.875 --> 18:03.145
There, there are some ways to do that, especially in,

18:03.285 --> 18:06.425
in many cases, in more, long-term illnesses

18:06.815 --> 18:09.185
that we are mission and so on and so forth.

18:09.645 --> 18:14.155
Um, complication, okay, so that's one another

18:15.025 --> 18:18.275
element that the literature has consisted as a study.

18:19.905 --> 18:24.265
Then the internalization principle also applies to

18:24.845 --> 18:26.465
organizational incentives.

18:26.975 --> 18:29.705
What do I mean by that? Patients get sick.

18:31.105 --> 18:35.325
It may involve a multi-stage, treatment protocol.

18:36.065 --> 18:40.285
You may be seeing, a a primary care doctor

18:41.185 --> 18:43.805
and given the complexity of your illness,

18:43.805 --> 18:47.085
primary care Dr. May refer you to a specialist

18:47.705 --> 18:52.255
and a specialist may consult and provide treatment,

18:52.395 --> 18:54.775
or maybe the specialist can send you back to the

18:55.355 --> 18:57.685
primary care, with suggestions.

18:57.685 --> 19:00.565
And so, right. So how do you make sure that this kind

19:00.565 --> 19:04.925
of referrals, this kind of reorganization re redirecting,

19:05.305 --> 19:09.155
is, is correct that simply

19:09.745 --> 19:14.145
will require you to pay the entire group of doctors.

19:15.525 --> 19:16.825
And they, and,

19:16.845 --> 19:20.145
and in the literature is sort of called the,

19:20.505 --> 19:22.385
organization incentives and payment.

19:23.045 --> 19:24.785
We don't pay a single doctor,

19:24.965 --> 19:26.425
we don't pay a single hospital.

19:27.045 --> 19:31.625
We pay a health plan to handle a sort of population

19:32.125 --> 19:33.845
of patients.

19:34.495 --> 19:37.275
And this will be maybe made on, on a yearly

19:37.295 --> 19:38.995
or long term, longer term basis.

19:40.615 --> 19:45.145
So this, sort of a summary

19:45.445 --> 19:50.145
of, of the ba the basic issue, the incentive in payment,

19:50.145 --> 19:52.185
what has been developed over the years,

19:52.325 --> 19:55.545
and it's a very short, of course, very concise summary.

19:56.165 --> 19:58.745
The, the literature is, is getting very big

19:59.325 --> 20:03.875
and we have many technical issues in terms of theoretical

20:04.395 --> 20:07.675
analysis and also in terms of the empirical work

20:07.785 --> 20:08.715
that has been done.

"Understanding Payment Incentives in the U.S. Healthcare System"

00:00:00 - Healthcare is a very important part of any society, and it's particularly important in the US because it occupies up to 20% of GTP. There are various ways that we can think about healthcare and, today I'm just going to concentrate on this element called payment incentives. There are other issues to think about, like insurance and so on, but they will be left on another location. So why are payment incentive at all relevant? The basic issue is that there are sort of three parties in this, in this scenario.
00:00:44 - and then they're the payers. It is like they interact. Consumers are patients. They want some services. Providers are medical personnel and facilities and healthcare professionals. And then the pay is a government, employers, insurance companies, public or private. It depends on various different countries. Basically, consumers demand and receive services from providers. The insurance will shield consumers from receiving, will shield consumers from part of the surface expenses.
00:01:25 - because illness carries some financial risk. And the insurance part says that when you seek medical treatment, both or part of the medical expenses will be paid for by the insurance company. Now this creates an obvious issue, which I'll come to in just one moment. who pays the bill? If consumers don't pay, the payers would have, would have to pay. So how, providers paid would
00:02:07 - If the payer can make providers be efficient so much, the better. And what are the ways to make them efficient? in the old days, like 50 years ago, 60 years ago is Medicare in the US and many other countries use something called fee for service or cost reimbursement. Whatever cost a provider incurs to surface consumers, the payer will just reimburse the expenses. of course this may often include a profit margin.
00:02:50 - because the profit margin then create an incentive problems. There will be more services provided and maybe qualities Can be made inefficiently high to attract services demanded by, demanded by consumers. The cost reimbursement fee for service has been regarded as a major reason for the high cost in the us That's one of course base payment mechanism. And there's an obvious incentive issue, then a popular, and now very, very common payment mechanism is called prospective
00:03:31 - It works like this. It works in two steps. First, we sort of define an episode of care. Let's say a patient gets into a hospital, eventually the patient gets discharged, and let's say this is a pneumonia episode. At the end of the episode, appoint discharge at that primary diagnosis called pneumonia will be associated with the patient and the discharge. Now this category of pneumonia will be associated with a price. This price will be the payment that the payer makes to the provider.

"Understanding Prospective Payment in Healthcare: Balancing Cost and Quality Incentives"

00:04:12 - No matter what kind of resources the provider has incurred. No matter how many days the patient stays in the hospital, it will be the same price. And, and it is very different from cost reimbursement. Cost reimbursement says, well, if you stay longer, we'll pay you more, stay shorter, we'll pay you less fixed price. Prospective payment says no matter what kind of resources you use, provided that you know the the provider, the hospital has to treat you in a satisfactory way. the payment will remains the same. So what does it aim to achieve?
00:04:52 - The two things that the provider does. The provider is gonna make quality decision and it's gonna make cost decisions. The quality decision can be associated with, nursing care, the, facilities, tests and any other things that, consumer, the patient may enjoy raising qualities will be sort of good for consumers and will raise demand, and consumers can be happier with higher quality. But of course, qualities can be very costly
00:05:35 - the hospital doesn't get paid more. So there is in some sense a way an incentive for the provider to reduce costs. Reduce costs, reduction of costs can happen in many ways. finding the right treatment, finding the appropriate treatment, and even the organization Of the hospital of the facility can sometimes affect costs. Okay, so these are the thing about this as the two decisions that a provider makes and, the cost reimbursement system that we,
00:06:14 - for service says that cost will always be paid for, even if I reduce cost, my payment would not get me more profit because it would just be reducing the reimbursement for me. Okay? Now, prospective payment doesn't work in the same way. Okay? And then, and let me now tie tie it to this, the sort of the economic principles involved in all this, and I call this the internalization principle. It applies in a very general setup, is not limited to healthcare. It says the following.
00:06:56 - that A desires A wants B to do something, A cannot control B'S behavior A cannot co B's action, then B must be made to share a's preferences. In other words, B must be made to internalize ace benefits and costs. I'll give you a very simple, since we are at a university, a very simple example, why do we think we have midterms and final? Why not have just the final exam? You see, once we have a midterm, that will be an incentive for students to study during the midterm
00:07:37 - And the final, of course, would be another way to motivate students to study during, during the second half of the semester. So if we want students to be studying throughout the semester, these two exams will be needed. So I as a professor warned my student to study gradually and consistently, and therefore I set up these two exams so that my preferences for their learning behavior will be more in, in line with their incentive to perform well in the exam. Now, of course, in quality choices to the satisfaction of the, of the payer, the provider makes two choices.

"Understanding Payment Incentives in Healthcare: The Internalization Principle and Its Implications for Cost and Quality Decisions"

00:08:24 - of principle, one and a half, the internalization principle, right? I, I want the payer to think of a way to internalize this cost and quality incentives, motivation, perspective by the provider. Okay? Now you think about that. Two things that I want to do. I need them to study first half and I want them to study second half of the semester. I need two exams. One exam isn't quite good enough, right? So you think about cost and quality choices
00:09:01 - You naturally think, well, we need two instruments. One needs an instrument to motivate cost incentives. One needs, an instrument to motivate, quality incentives. Now, what is the beauty of the prospective payment? What does the pro prospective payment say? Is the provider is responsible for cost no matter what the cost is, the payment from the payer to the provider is constant. In other words, it internalizes cost, so to speak. The provider under this payment mechanism has already
00:09:45 - So what are we left behind with? We are left behind with the second instrument. The price, higher price would therefore encourage higher quality, lower price can, encourage or discourage higher quality. Okay, let's say you have this patient who has pneumonia being admitted to the hospital, right? So how many days to stay? okay, well, the hospital has to bear the cost. You cannot just send away the patient when the patient is very sick. the quality of care now depends on what, depends on how much the hospital is paid.
00:10:26 - then we have an incentive to provide, would've an incentive to make the patient happier. So the price can be adjusted to align some incentive. The price can be made, can be set. So the provider to internalizes the benefit. So that's the internalization principle. The provider wants, the, the, the payer wants a provider to have efficient cost and quality decisions. And the way to do it is to ask the provider to internalize the cost and benefit the desirable part
00:11:09 - and quality incentives. We have one instrument because the prospective payment is a single price. However, the beauty of prospective payment is that cost is already internalized. By definition, the provider has to bear the cost. So we have, we have full efficiency in this, in this scenario. Now, it also brings out the issue about fee for service. Fee for service would never induce efficiency simply because cost is always reimbursed. That part of the sort of the equation of the incentive is never internal
00:11:50 - Alright? So that's the sort of the literature I I sort of started, about 30 years ago is, one of the first papers to recognize that, providers behavior can be multifaceted. They have many things that they can do, some concern causing some concern, quality and different payment mechanism is steering them towards different kinds of behavior, right? It's simple model, but we always start with simple model because we can derive insights and then we can continue to work on the same principle, but relaxing various, restrictions.

Examining the Challenges of Prospective Payment in Healthcare: Dumping and Cream Skimming**

00:12:32 - way back when people already spotted some issues with prospective payment. the prospective payment suffers from some well-known problems. It's called dumping and cream skiing. So what is dumping? Dumping refers to the idea that to make money a provider can simply turn away very expensive patients. It's quite illegal in many countries, in most countries. but it doesn't stop people, providers from hinting, for example, that your case may, your maybe better off being treated elsewhere.
00:13:12 - and some persuasion can drive some expensive patients to other providers, right? This is called dumping and cream skimming, refers to higher quality to attract more attractive to, to, to, to get more, profitable patients. So this is the idea. Well, in, in the case of services, maybe we are going to have very good pre-op services before the operation, before, the actual procedure. We, we will advise you on what to do, what not to do, and
00:13:55 - Although, you know, surgery may never be a good experience, it is going to be sort of a, a more welcoming strategy. Okay? So what is the catch? What what is the problem with prospective payment? You ask consumers, you ask providers to bear the full cost, but they don't have to bear the full cost. If they understand that they can turn away some very expensive or costly patients. So this idea is called dumping and cream ischemic, okay? Cost variations therefore may limit the power of prospective payment selection incentive.
00:14:33 - and cream skimming, may be avoided by fee for surface. So I'm not going to argue that fee for surface is completely useless in the case of, cost variation. then fever surface can eliminate some sort of undesirable dumping or cream scheme. It's still a fairly simpl simplistic scenario. But notice what I've done. I have started with the internalization principle and then I've started counting. I've got a mechanism, I've got payment method
00:15:16 - and I've listed two things that the provider is doing, like cost and quality. I have successfully introduced more and more actions available to the provider, selecting patients, getting the good risk, getting the less expensive patients. so now I have sort of three problems. And now prospective payment has only one single instrument, although it does force the provider to internalized costs, right? As you gradually make the situation more and more complicated, if you allow, the provider
00:16:00 - over its profit maximization attempt, you're gonna see that none of the mechanism that we have ever considered is sort of completely foolproof. There will be some sort of trade off the extent literature has sort of documented this kind of trade off in the past 30 years or so, we have expanded this literature into various scenarios. the extent literature is about making the analysis more realistic and more practical. First, I was just talking about providers as if they were just trying to maximize their profit.

"Balancing Altruism and Financial Incentives in Healthcare Payment Models"

00:16:44 - the correct assumption. They may be a little bit altruistic. They may love their patients to some extent they care about consumer's wellbeing. Now that element alone is not that hard to to handle. if you love your patients 50%, well, okay, I'm, I'm, I'm going to ask you to bear 50% of the cost. I'll reimburse you 50% of the cost, but not everything. The price will be adjusted because I know that I don't need a lot of incentive for you to provide for it, right? So this mixing fee for service and prospective payment together is a very effective way
00:17:29 - And that has been done over the years, in, in various papers. Then in more recent years, we have expanded sort of discussions about, for example, pay for performance. we are not just paying for the discharge. We like to assess how well the patient is, is feeling after a certain amount of time period. Is there any way that we can assess, performance by the provider? There, there are some ways to do that, especially in, in many cases, in more, long-term illnesses
00:18:09 - complication, okay, so that's one another element that the literature has consisted as a study. Then the internalization principle also applies to organizational incentives. What do I mean by that? Patients get sick. It may involve a multi-stage, treatment protocol. You may be seeing, a a primary care doctor and given the complexity of your illness, primary care Dr. May refer you to a specialist
00:18:52 - or maybe the specialist can send you back to the primary care, with suggestions. And so, right. So how do you make sure that this kind of referrals, this kind of reorganization re redirecting, is, is correct that simply will require you to pay the entire group of doctors. And they, and, and in the literature is sort of called the, organization incentives and payment. We don't pay a single doctor, we don't pay a single hospital. We pay a health plan to handle a sort of population
00:20:07 - And this will be maybe made on, on a yearly or long term, longer term basis. So this, sort of a summary of, of the ba the basic issue, the incentive in payment, what has been developed over the years, and it's a very short, of course, very concise summary. The, the literature is, is getting very big and we have many technical issues in terms of theoretical analysis and also in terms of the empirical work that has been done.

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