Purchasing Primary Care Services for Quality Chronic Care: Capitation With Performance Payments in Four Countries

Area of Science:

• Health Services Research
• Public Health Policy
• Non-communicable Disease Management

Background:

• Improving care quality for chronic conditions is vital for reducing premature mortality from non-communicable diseases.
• Health care purchasing arrangements are being explored to enhance service delivery and outcomes.

Purpose of the Study:

• To present results from case studies on health care purchasing arrangements using capitation with performance pay.
• To evaluate the impact of these payment methods on service quality and health outcomes for chronic conditions.

Main Methods:

• Case studies of primary care providers in Chile, China, Indonesia, and South Africa.
• Implementation of capitation with performance pay, alongside enabling interventions like training and non-financial incentives.

Main Results:

• Incentives were insufficient to drive significant provider behavior change for quality improvement.
• Design and implementation challenges (e.g., voluntary enrollment, quality metrics, risk adjustment, payment certainty) led to low patient volume and uptake, reducing expected effects.
• Uncertainty in payment timing/levels and withholding payments potentially undermined impact.

Conclusions:

• Adjusting quality measures for patient health risk and complexity is essential to avoid penalizing providers.
• Relative or progressive quality targets may be more suitable for diverse provider capacities and national programs.
• Addressing design and implementation challenges is critical for effective payment reforms in chronic condition care.