Cultural and behavioural barriers to the successful implementation of new models of care in healthcare systems are present at three distinct levels: (i) system; (ii) clinic/provider; and (iii) individual.
To overcome this challenge, appropriate incentives should be used that help different stakeholders operating at these levels achieve their respective aims and goals – healthcare providers in particular.
Appropriate, simple and aligned financial incentives for providers can be effective tools to ensure rapid and effective change1, especially when compared to other dimensions such as professional ethos and education that have historically seen less success in changing behaviour2.
However, there must be a recognition from the system and providers that benefits will only be realised after a number of years, financial incentives alone will unlikely be a sufficient condition of success for implementing an integrated care system, and best practice examples may not be transferable across different health systems3. In this regard, providers must be confident that that they will be able to benefit from investments4. The following case study outlines how financial incentives have been used to overcome cultural and behavioural barriers at a provider, system and local level.
Gesundes Kinzigtal case study
The German ‘Kinzigtal (healthy) approach’ set up in 2005 aimed to improve the health of the regional population, raise patient experience of care and eliminate unnecessary costs by harnessing shared saving contracts between a healthcare management company and a regional network of physicians in the Kinzigtal region of South West Germany. This approach is based on the ‘Triple Aim’ framework developed by the Institute for Healthcare Improvement5.
Gesundes Kinzigtal (the provider/management collaboration) identified two principal ways to enable early intervention, achieve better health outcome, and generate efficiency savings: (i) focusing on prevention; and (ii) better management of care processes. Their approach, which took over five years, €1 million investment and trust between providers to realise6, can be broken down into five distinct components:
- Individual treatment plans agreed between the clinician and the patient
- Patient self-management and shared decision-making
- Follow-up care and management
- The ‘right care at the right time’
- Digitised patient record system to analyse data and identify high-risk patients to allow for early interventions
This in turn was facilitated by shared peer consultation among care providers. For example, on six occasions per year, physicians meet with a specialist pharmacologist to assess and evaluate the value of patient medication regimes.
Providers continue to receive ‘normal’ fees directly though ‘sickness funds’ (statutory health insurance) and also benefit (based on performance) from the company’s profit generated through efficiency savings and shared with the healthcare management company7. The payments typically constitute 10-15% of the providers’ incomes.
External and internal evaluation has shown that Gesundes Kinzigtal has led to improved health and expenditure outcomes. The success of the initiative can be measured several ways: by analysing health outcomes, patient experience and cost-savings. The following infographic demonstrates how Gesundes Kinzigtal has delivered on all three indicators. An additional indicator, hospital admissions, also shows improved results: -10.2% vs 33.1% control.
A study conducted by the University of Freiburg in 2014 also showed that the number of people in the region who felt they lived more healthily was significantly greater among Gesundes Kinzigtal.9
The ‘Kinzigtal approach’ also incorporated a number of patient incentives separate from improved health outcomes. All enrolled members had flexibility in the choice of healthcare provider, access to physicians outside of standard working hours as well as discounted gym membership and tailored physical exercise programmes developed in collaboration with fitness trainers and physiotherapists.
The ‘Kinzigtal approach’ has demonstrated the success of a model that strives to improve patient outcomes and reduce system costs.
1 Tsiachristas, A., Dikkers, C., Boland, M. R. and M. P. Rutten-van Mölken. (2013). Exploring payment schemes used to promote integrated chronic care in Europe. Health Policy, 113(3), 296–304.
2 Busse, R. and N. Mays. (2008). Paying for chronic disease care. In: Nolte, E. and M. McKee (eds). Caring for people with chronic conditions: A health system perspective. Maidenhead: Open University Press, 195–221.
3 London School of Economics. (2013). Incentivising Integrated Care. Available at: http://www.lse.ac.uk/LSEHealthAndSocialCare/pdf/eurohealth/Eurohealth_volume_19_issue_2.pdf
4 Busse, R., Blumel, M., Scheller-Kreinsen, D. and A. Zettner. (2010). Tackling Chronic Disease in Europe: Strategies, Interventions and Challenges. World Health Organization.
5 Institute for Healthcare Improvement. (2017). Triple Aim. Available at: http://www.ihi.org/Topics/TripleAim/Pages/default.aspx
6 London School of Economics. (2013). Incentivising Integrated Care. Available at: http://www.lse.ac.uk/LSEHealthAndSocialCare/pdf/eurohealth/Eurohealth_volume_19_issue_2.pdf
7 Busse, R. and J. Stahl. (2015). Integrated Care Experiences and Outcomes in Germany, the Netherlands and England. Health Aff (Millwood), 33(9), 1549–1558. Available at: https://www.regione.veneto.it/c/document_library/get_file?uuid=ac51c5f6-820a-4a0c-ac44-7899366b9b35&groupId=10793
8 NHS Confederation. (2017). Gesundes Kinzigtal study visit. Available at: http://nhsconfed.org/regions-and-eu/nhs-european-office/eu-knowledge-sharing/eu-models-of-care/gesundes-kinzigtal-study-visit-february-2016
9 Siegel, A. and U. Stößel. (2014). Patientenorientierung und Partizipative Entscheidungsfindung in der Integrierten Versorgung Gesundes Kinzigtal. In: Pundt, J. (Hrsg.) Patientenorientierung: Wunsch oder Wirklichkeit? 195-230.