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Outcomes-Adjusted Reimbursement in a Health-Care Delivery System

Author

Listed:
  • Prashant C. Fuloria

    (Closed Loop Solutions, Inc., Redwood City, California 94063)

  • Stefanos A. Zenios

    (Graduate School of Business, Stanford University, Stanford, California 94305)

Abstract

This paper considers a health-care delivery system with two noncooperative parties: a purchaser of medical services and a specialized provider. A dynamic principal-agent model that captures the interaction between the two parties is developed. In this model, patients arrive exogenously, receive periodic treatment from the provider, suffer costly complications that require hospital care, and eventually exit the system in death. The provider chooses the intensity of treatment in each period, incurs an associated cost, and is reimbursed by the purchaser according to observed patient outcomes. The purchaser's problem is to determine a payment system that will induce treatment choices maximizing total social welfare. The optimal payment system, referred to as the outcomes-adjusted payment system, is identified. It consists of a prospective payment per patient and a retrospective payment adjustment based on adverse short-term patient outcomes. This system induces the most efficient delivery of medical services by combining the immediate "threat" of a retrospective payment adjustment with the future reward of prospective payments generated by surviving patients. A numerical example is provided in the context of Medicare's End-Stage Renal Disease program. The example compares the optimal system to systems that are currently in place. The results suggest that the purchaser can achieve significant gains in patient life expectancy by switching to the outcomes-adjusted payment system, but this requires accurate information about treatment technology, patient characteristics, and provider preferences. The life-expectancy gains do not involve increased medical expenditures.

Suggested Citation

  • Prashant C. Fuloria & Stefanos A. Zenios, 2001. "Outcomes-Adjusted Reimbursement in a Health-Care Delivery System," Management Science, INFORMS, vol. 47(6), pages 735-751, June.
    • Handle: RePEc:inm:ormnsc:v:47:y:2001:i:6:p:735-751
    DOI: 10.1287/mnsc.47.6.735.9816
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    Cited by:

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    4. Pengfei Guo & Christopher S. Tang & Yulan Wang & Ming Zhao, 2019. "The Impact of Reimbursement Policy on Social Welfare, Revisit Rate, and Waiting Time in a Public Healthcare System: Fee-for-Service Versus Bundled Payment," Service Science, INFORMS, vol. 21(1), pages 154-170, January.
    5. Hui Zhang & Christian Wernz & Danny R. Hughes, 2018. "Modeling and designing health care payment innovations for medical imaging," Health Care Management Science, Springer, vol. 21(1), pages 37-51, March.
    6. Hongmin Li & Hao Zhang & Charles H. Fine, 2013. "Dynamic Business Share Allocation in a Supply Chain with Competing Suppliers," Operations Research, INFORMS, vol. 61(2), pages 280-297, April.
    7. Michaela-Maria Schaffhauser-Linzatti & Achim Zeileis & Marion Rauner, 2009. "Effects of the Austrian performance-oriented inpatient reimbursement system on treatment patterns: illustrated on cases with knee-joint problems," Central European Journal of Operations Research, Springer;Slovak Society for Operations Research;Hungarian Operational Research Society;Czech Society for Operations Research;Österr. Gesellschaft für Operations Research (ÖGOR);Slovenian Society Informatika - Section for Operational Research;Croatian Operational Research Society, vol. 17(3), pages 293-314, September.
    8. Tinglong Dai & Sridhar Tayur, 2020. "OM Forum—Healthcare Operations Management: A Snapshot of Emerging Research," Manufacturing & Service Operations Management, INFORMS, vol. 22(5), pages 869-887, September.
    9. Elodie Adida & Hamed Mamani & Shima Nassiri, 2017. "Bundled Payment vs. Fee-for-Service: Impact of Payment Scheme on Performance," Management Science, INFORMS, vol. 63(5), pages 1606-1624, May.
    10. Xiuli Chao & Liming Liu & Shaohui Zheng, 2003. "Resource Allocation in Multisite Service Systems with Intersite Customer Flows," Management Science, INFORMS, vol. 49(12), pages 1739-1752, December.
    11. Diwakar Gupta & Mili Mehrotra, 2015. "Bundled Payments For Healthcare Services: Proposer Selection and Information Sharing," Operations Research, INFORMS, vol. 63(4), pages 772-788, August.
    12. Yaesoubi, Reza & Roberts, Stephen D., 2011. "Payment contracts in a preventive health care system: A perspective from Operations Management," Journal of Health Economics, Elsevier, vol. 30(6), pages 1188-1196.
    13. Adam Powell & Sergei Savin & Nicos Savva, 2012. "Physician Workload and Hospital Reimbursement: Overworked Physicians Generate Less Revenue per Patient," Manufacturing & Service Operations Management, INFORMS, vol. 14(4), pages 512-528, October.
    14. Hamsa Bastani & Joel Goh & Mohsen Bayati, 2019. "Evidence of Upcoding in Pay-for-Performance Programs," Management Science, INFORMS, vol. 65(3), pages 1042-1060, March.
    15. Fainman, Emily Zhu & Kucukyazici, Beste, 2020. "Design of financial incentives and payment schemes in healthcare systems: A review," Socio-Economic Planning Sciences, Elsevier, vol. 72(C).
    16. Houyuan Jiang & Zhan Pang & Sergei Savin, 2012. "Performance-Based Contracts for Outpatient Medical Services," Manufacturing & Service Operations Management, INFORMS, vol. 14(4), pages 654-669, October.
    17. Donald K. K. Lee & Stefanos A. Zenios, 2012. "An Evidence-Based Incentive System for Medicare's End-Stage Renal Disease Program," Management Science, INFORMS, vol. 58(6), pages 1092-1105, June.
    18. Houyuan Jiang & Zhan Pang & Sergei Savin, 2020. "Performance Incentives and Competition in Health Care Markets," Production and Operations Management, Production and Operations Management Society, vol. 29(5), pages 1145-1164, May.
    19. Hui Zhang & Christian Wernz & Anthony D. Slonim, 2016. "Aligning incentives in health care: a multiscale decision theory approach," EURO Journal on Decision Processes, Springer;EURO - The Association of European Operational Research Societies, vol. 4(3), pages 219-244, November.
    20. Diwas S. Kc & Christian Terwiesch, 2009. "Impact of Workload on Service Time and Patient Safety: An Econometric Analysis of Hospital Operations," Management Science, INFORMS, vol. 55(9), pages 1486-1498, September.
    21. Li, Zhong-Ping & Wang, Jian-Jun, 2021. "Effects of healthcare quality and reimbursement rate in a hospital association," Socio-Economic Planning Sciences, Elsevier, vol. 76(C).
    22. Evrim Güneş & Stephen Chick & Luk Wassenhove, 2010. "Quality competition for screening and treatment services," Annals of Operations Research, Springer, vol. 178(1), pages 201-222, July.
    23. Houyuan Jiang & Zhan Pang & Sergei Savin, 2017. "Improving Patient Access to Care: Performance Incentives and Competition in Healthcare Markets," Working Papers 2017/01, Cambridge Judge Business School, University of Cambridge.
    24. Brandon Pope & Abhijit Deshmukh & Andrew Johnson & James Rohack, 2014. "Multilateral Contracting And Prevention," Health Economics, John Wiley & Sons, Ltd., vol. 23(4), pages 397-409, April.

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