PERFORMANCE-BASED PAYMENT SYSTEM IN THE MINISTRY OF HEALTH PRACTICES

Our experience has shown us that just encouraging and reminding health care professionals their responsibility for giving productive and qualified health care services, though being a pre-condition, is not sufficient alone. We also know that the search for such models, which will ensure the sustainability of efforts and enhance responsibility of employees, widely occupies the agenda of policy-makers in health. The Ministry of Health has put signature under rapid changes in health sector for the last few years. Main target of these changes is to establish a system, which presents the ways for higher motivation of service providers and which is capable of using the instruments needed for delivery of productive and qualified health care services.

One of the most prioritized steps taken to this end is the performance-based contribution payment, which aims to establish a payment and pricing system that will encourage service providers for delivering productive and qualified health care services. Performance-based contribution payment system, which was first a pilot implementation at 10 hospitals in the second half of the year 2003, has been implemented across Turkey from 2004; it has also covered the primary care. There are mainly two phases of the implementation which has been conducted up to now. One-year practice made in 2004 facilitated the adaptation of health care professionals and facilities to the new condition and paved the way for inspections and audits to sustain the measurement of performance. Considering the changes and experience, a limited number of quality criteria easily measurable in domestic conditions were tested and the most eligible ones were put into practice in the year 2005.   

1- Individual Performance Measurement

As the first step, an innovative model, which is convenient for domestic conditions in Turkey, was developed by means of directives that envisage to identify individual performance at primary care facilities and hospitals and to make contribution payment based on this performance. 

 
Labor intensive medical services, according to their significance and frequency, were scored and the services given by physicians were made measurable on a monthly basis.   

Individual services given by physicians were made measurable as much as possible and the system was promoted by strengthening patient-physician relations and patient’s right to choose physician.

Considering the fact that delivery of health care services is a team product, non-clinic physicians, other health employees and managers were scored in accordance with the average score of their institutions. So, total performance of the institution is reflected upon all employees.  

As for the monthly revenues at institutions, which are distributed to employees as legal contribution payment, every other employee could have a share based on his/her individual performance and score. So, employees make contribution to and have a share in positive values produced by their institutions.

As for calculating the scores of physicians, a difference is emphasized between two groups, working in public sector on part-time and full-time basis. So, full-time working in public sector is subsidized.

Providing that the incentives which aim to prevent hospital infections, within the main framework identified, are achieved on a regular basis, then physicians of relevant branches will be awarded, as well.

The necessity of a registry and information system which would provide a proper follow-up of service quality and quantity, is a common known fact. For regular collection of monthly data, keeping the services of employees under record, transmitting these records to reimbursement agencies and calculating the score distribution of institution in a transparent and realistic way, hospital information systems rapidly has begun to become widespread. Hospital information systems, though not being a provision in this directive, turned out to be a natural outcome of the directive. This is the first time that health care services are kept under numerical records to such an extent so far.   

Directive does not measure financial performance directly. However, monetary value of calculated scores is in parallel with the monetary positive value which is created by the institution that month. For this reason, this implementation indirectly influences to financial performance like decline in per unit costs, saving in current expenditures, check of the patient’s hospital admission date and increase in the investment in curative devices and infrastructure.

At training and research hospitals, additional scores are given to clinic chefs, deputy chiefs, chief interns and specialists providing that they make publications of a definite number. Clinic chefs and deputy chefs at training and research hospitals are also given additional scores providing that they give certified theoretical and practical trainings of a certain level. Thus, uncompetitive performance criteria are used in the field of scientific publications and specialty training. 

Commissions, which are set up in provincial health directorates for primary care facilities and at hospitals,  with the participation of representatives from different professions,  determine the amount of contribution payment to the personnel by considering income-expense balance, debts, credits, fiscal status and needs of the institution. Thus, participation of different groups and levels in hospital management is encouraged and the capacity of at-site administration is promoted.

In order to ensure that health care services given in health facilities are being kept in record regularly and invoices sent to institutions are being arranged unerring, the system of auto-control in every facilities is put into practice. This is achieved by the way of inspection committees, set up at hospitals for the aim of evaluating and controlling the quantity, quality and appropriateness of services to determined principles. Negative attitudes detected in measuring performance might be punished.  

Based on distance of primary care facilities from city/town centers, facilities such as transportation and considering if they are located in villages, towns, districts or city centers, onsite classification is made and so a discrepancy is formed, and in return for working in deprivation regions, higher premiums are given.

As for health care services given in primary health care facilities, various factors such as the follow-up of infants, pregnant, the number of vaccination, new-born scanning tests and use of modern family planning methods are also used as performance criteria. Thus, preventive health care services are also awarded and encouraged.

2- Quality Development and Measurement of Institutional Performance

With directive on the measurement of institutional performance which was put into effect in the second half of the year 2005, performance evaluation system, which was predominantly implemented based on the quantity measurement and related criteria, was enlarged by an attempt to measure the quality. Sanctions on developing institutional quality both cover internationally accepted hospital quality criteria and meet our domestic needs. Integral performance of health facilities could be measured by evaluating these criteria. By this way, numerical comparison and success rate of hospitals could be available.   

Final performance level of the institution serves as the factor to convert individual performance scores to the amount of contribution payment. In other words, councils at institutions, which used to identify the needs and make financial allocation in the past, were replaced by the degree of institutional performance. In brief, individual performance, which is the same as at another institution, is awarded more if it is available at an institution with higher institutional performance. So, the award given for quantity is determined by quality.  

Difficulty, complexity and ambiguity nature of quality measurement was mentioned before. Taking this point as the basis, no one can claim that the Ministerial practices are excellent. However, when the public hospitals’ accumulation, capability and capacity is taken into consideration, it is obvious that objective criteria are tried to be implemented as much as possible. Implementation and practices up to now are, naturally, limited in regarding applicability and objectivity. There are still some defects and/or shortcomings to remedy.

At this implementation, methods of institutional performance measurement are classified in four groups, which are outpatient services, hospital quality criteria, supervision of hospital infrastructure and processes, and measurement of patient’s satisfaction, as well.

a) Outpatient Services

Being a method of hospital performance measurement and regarding patient’s treatment services, allocating a separate room for every other physician, though not being recommended by the World Health Organization, is adopted as acceptable indicator for our country in the beginning (32). We know that steps to be taken to facilitate patients’ access to health care services are among our objectives with high priority. We are also aware of the significant deficit in the number of physicians in our country. Establishing a system, in which all physicians are assigned with active tasks and the burden of system is equally distributed to meet demand, will facilitate fair distribution of patients to physicians and thus will ensure longer period of treatment per one patient. It will also enable patients to choose their physicians. That is why such a change is adopted and implemented in Turkey.  It could also be used as an instrument to increase the quality of infrastructure and inputs in basic performance criteria. It is vital even for a first step to a more qualified health system. However, supporting that with the criteria such as determination of the minimum time for each patient will be useful.

b) Hospital Quality Criteria

As for the quality measurement of hospital services, 100 criteria were selected among the international accreditation standards (developed by the Joint Commission International Accreditation). They were tested at our hospitals and then evaluated in national scale. These criteria usually focus on patients evaluation, patients care, access to and sustainability of care, training for patients and their families, rights of patients and their families, management, managerial skills, steering, qualification and training of employees, quality improvement and patients safety, information management, facility management and security, control and prevention of injections.   

Although external assessment is not a pre-condition at this point, this implementation is very important for creating awareness of quality at an institution. The system will be promoted once more criteria are embedded after they are tested and the practices are audited by independent external auditors. When the scope of quality criteria is taken into consideration, it could be thought that the process of service delivery partially is tried to be awarded. Measurement of the process, however, focuses on the process of service delivery and aims to award evidence-based well medical practices.  It is, in other words, more inclusive. On the other hand, it is a topic which is considered rather in theory and which is subject to severe discussions.

c) Supervision of Hospital Infrastructure and Some Processes

Control on hospitals infrastructure is the liability of provincial health managers. Hospitals are supervised based on a control scheme. Although supervision of hospitals did not have a significant role in past practices, today it is requested by hospital managers and employees since it is closely linked to contribution payment.  In this context, various factors such as physical condition, personnel, management, equipment, device, information processing infrastructure and environment at a hospital are assessed first. Thus, problems at that hospital are detected and provincial administrators come to know these problems. The said supervision also enables to measure the quality of hospital infrastructure and inputs which are health service performance criteria. On the other hand, it could be criticized because of not having recording system for sufficient number of qualified and trained personnel, and taking on the information systems superficially. However, it should be kept in mind that what we try to achieve is to make performance evaluation which is applicable in conditions at public hospitals.    

d) Measurement of Patient Satisfaction

Questionnaires were developed to measure the level of satisfaction for patients and their families. Two sets of questionnaires and questionnaire principles were developed for in-patient and out-patient health care receivers. Thus, not only patients but also their families were covered in the process of health service performance measurement. As known, patient satisfaction is one of the most important instruments of competitive systems, and the most tangible evidence in health sector is patient satisfaction and happiness. All parties and shareholders in health sector agree upon that patient satisfaction should be taken into consideration as the performance evaluation criteria. That is why hospitals were encouraged to conduct these questionnaires in the beginning. By this way, corporate capacity could be developed. It will become much more useful once it is conducted by independent agencies out of these institutions.   

Through such practices, quality criteria evaluation and questionnaire conduct units have been set up at all hospitals and the concept of health services quality has been introduced to all managers at public hospitals.

3- Progress in Measurement of Performance

As we all know, various performance criteria are discussed to ensure productivity and quality in health care services. Compliance with a well-defined health care services delivery of higher quality, meeting the norms defined in relation to the utilization of infrastructure,  human resources and material supply (input), achieving a better level of health (output) and making service receivers happy are the main pillars of these criteria.  

If we assess current practices with respect to performance criteria at health care services, we could say that these criteria are tried to be utilized even with limits. Practices regarding the measurement of patient satisfaction and infrastructure are relatively more tangible. Measurement of the process, however, is limited and measurement of outputs is not available for now. Further studies are required to measure clinical process and outputs, on the other hand. Encouraging and facilitating such efforts will pave the way for studies in the future.

It should be kept in mind that functioning of the output-based performance measurement is still under debate although it is agreed in theory. We also know that it is difficult to determine the power of data, which constitutes the background of a well clinical practice in process analysis. As discussed above, gaps occur while evaluating evidence-based nature of a well clinical practice and these gaps are usually filled with subjective judgments. Thus, it should not be forgotten that the subjects, which seem like defects or shortcomings, are very controversial ones under hot debates, in fact.   

Prof. Dr. Sabahattin Aydın