The Development and Evaluation of Hospital Pay-for-Performance in Lebanon: Casemix, Readmissions and Patient Perspectives

Sammanfattning: Background: Pay-for-performance (P4P) has been widely used in healthcare, but there are few experiences of hospital-based P4P at scale. The evidence of impact from these has been mixed, and there has been increased recognition of the importance of different contexts, designs, incentives and other factors. In 2014, the Lebanese Ministry of Public Health integrated a P4P model for determining hospital reimbursement tiers. In 2018, this model was updated to include a readmissions component, in addition to the preexisting components such as casemix and patient satisfaction. The impact of these interventions was previously undetermined. This also provided an opportunity to contribute to some of the known knowledge gaps regarding hospital P4P. The purpose of this thesis was to describe the development and evaluate the impact of hospital P4P in Lebanon, and ultimately to contribute more broadly to improved design and implementation of value-based healthcare, particularly in limited resource settings.Methods: This thesis uses a mixed methods approach, combining quantitative and qualitative study designs, to conduct four research investigations. The first paper uses descriptive analysis to address how and why hospital P4P was developed in Lebanon. The second and third papers both use an interrupted time series design on data collected from the Ministry hospitalization database. The former uses Newey-OLS regression, and the latter uses Autoregressive Integrated Moving Average models. The second paper analyzes the impact of the 2014 P4P integration on casemix index, and the third paper analyzes the impact of the 2018 model update on readmissions. The fourth paper uses qualitative content analysis on data collected from eight focus groups discussions with patient participants.Results: The Ministry developed hospital P4P after recognizing the limitations of the previous model that had been solely based on accreditation status. Casemix index was included in the P4P model, to improve the appropriateness and fairness of the Ministry-hospitals relation. The analysis of P4P integration impact on casemix included 1,353,025 hospitalizations between 2011 and 2016. This revealed an abrupt increase in casemix among short-stay cases, and a gradual increase in medium-stay cases. Code-level analysis suggested this was attributable to a decrease in unnecessary hospitalizations and improved coding practices. The analysis of P4P impact on readmissions included 1,333,691 hospitalizations across 2011-2019. An abrupt decrease of cholecystectomy and stroke readmissions was found, but not of general and pneumonia readmissions. Our qualitative investigation allowed us to identify six patient perspectives, including satisfaction, health status, perceptions on each of quality, access and health system, and valuing of health, all of central relevance to health systems performance.Conclusion: Hospital P4P in Lebanon led to several positive impacts, including improving the relation between hospitals and the Ministry of Public Health, and providing a tool for continuous development of the health system. The 2014 and 2018 P4P interventions improved system effectiveness and related patient outcomes, by decreasing unnecessary hospitalizations and decreasing some types of readmissions. The Ministry should develop its P4P model to capture the entire spectrum of hospital visits. Using appropriate interrupted time series analysis on readily available data is a useful way to evaluate the effects of health system interventions in contexts with limited resources. Patients in Lebanon highly valued health and supported improving public hospitals and measures to counter the influence of personal connections and money. Health systems canmore widely engage people for their perspectives, and patients can have a fundamental role in shaping the values and functions of a health system.