Insentif

Incentive schemes for readmissions reduction in coordinating reverse referral healthcare services

Context: China to reduce readmissions to the hospital

Dari yang gw lihat, ini konteksnya di China dan system referral systemnya itu di-lead oleh RS utama di
kota itu, yang memberikan insentif ke Community Health System (CHS)nya juga RSnya. Di konteks ini,
tujuannya untuk mengurangi readmissions ke RS karena dianggap dapat memperburuk covid-19 karena
semakin ramai yang masuk RS. Jadi mereka kasih opsi 3 insentif untuk mengurangi readmissions ke RS.
Hasilnya Bundled Payment (BP) dan Penalty Contract (PC) yang dianggap cocok.

Three options for incentives schemes:

• Fee-for-service (FFS) arrangement under which the provider (community hospital) receives a
payment each time a patient is admitted (or readmitted)
o FFS can only induce the city hospital herself to exert the first-best effort but provide no
incentive for the community hospital
o FFS is not suggested to be adopted by the city hospital since it leads to poor patient
outcomes, that is, high readmission of patients
• bundled payment (BP), under which the provider is compensated with one lump sum for a
whole episode of care
o BP can generally coordinate the effort decisions with the first-best, that is, coordinated
care is effectively delivered to patients
o the city hospital can provide a BP contract with specific transfer price to incentivize
herself and the community hospital to deliver coordinated care to patients with chronic
disease
• Penalty contract (PC), under which the provider receives a fixed fee per patient and is
retrospectively penalized for treatment failures
o PC cannot simultaneously align both hospitals’ effort decisions to the first-best, but it
can incentivize both hospitals to exert more than their first-best efforts and thereby
trigger improvement for readmission reduction at a slight increase of the total costs
o in a healthcare system where reducing readmission is a relatively vital objective, the city
hospital, as the leader, can offer a PC contract with specific transfer price and penalty
rate to induce both hospitals to exert more efforts than their first-best with the total
costs slightly increase
Behavioural Change:

Effect of Response and Knowledge About Back-Referral Program Toward Patient's Obedience at the
Fatmawati National Vertical Hospital

https://www.neliti.com/publications/510545/effect-of-response-and-knowledge-about-back-referral-
program-toward-patients-obe :

Ini penelitian membahas tentang kepatuhan pasien untuk mengikuti PRB. Hasilnya, kurangnya
awareness pasien dan pelayanan kepada pasien jadi faktor yang mempengaruhi kepatuhan pasien.
Karna itu, rekomendasi biar pasien patuh itu harus ada sosialisasi PRB jadi pasien paham manfaat yang
mereka dapat. Juga Puskesmas perlu dikuatin dari fasilitas sampai SDMnya biar pasiennya mau dirawat
disana.

Reasons not to refer eligible patients to behaviour-change programmes at the municipal

• Education becomes the basis of action (Notoatmodjo 2003). If a patient had limite dknowledge
about some program, they would not obey the program. Patients do nothave any idea
about the program, benefits and their loses if they follow the plan. So, thesolution for this
problem is to socialize back-referral program to social, national healthinsurance patient. Patients
should explain what the benefits they will gain if they followand obey this program. Therefore,
patients are expected to increase their knowledgeabout the program and will affect their
behavior to obey the back-referral program.
• Besides the patient’s knowledge, the result showed that responsiveness of hospitalworker
influence patient’s obedience toward the back-referral program. This hospitalworker’s
responsiveness was described by how hospital managed their worker to ser-vice the patients.
The result showed that the patient gave a functional assessment forThe Fatmawati National
Vertical Hospital’s responsiveness. Started from patient reg-istration to patient treatment,
 the patient agreed that The Fatmawati National VerticalHospital’s service was quick and
precise. Reactivity included in patient satisfaction andquality of care, but it’s a distinct entity that
refers to the way individuals treated and theenvironment in which they managed when seeking
health care (WHO 2000; Figueras2004; Saltman 2004; Mohammed 2013). A responsive health
insurance scheme ensuresthat users can obtain healthcare in a client-oriented manner with no
discrimination ofdifferent population groups (WHO 2000; Carrin 2004; Carrin 2005)
• From this study, we assumed that back-referral program has not been functioning
effectively from both primary health care side and social health insurance side. For primary
health care, the solution is to strengthen primary health care because it is essentialto improve
access and quality of health care especially in low/middle income countries(Lerberghe 2008).
Implementing effective interventions to strengthen primary concer nhas been challenging, and
many efforts have limited success because of insufficient financial resources, weak political
engagement, or inadequate management of the refer-ral patterns of patients using primary
health centers and secondary hospitals. A key element of primary health care is its referral
system in which patients can access care at community-based health posts or health centers
before accessing higher-levels of con-cern such as secondary and tertiary hospitals. Other
studies also have found that suchincreased use of primary care facilities is a cost-effective
investment and can improvehealth outcomes (Bradley et al. 2011; Gebrehiwot et al. 2012; Curry
et al. 2013).
• And for social health insurance organization, the solution is to increase public aware-ness for the
back-referral program. The is similar with Abraham’ study, stating that gen-eral knowledge for a
referral or back-referral system must be improved, such as provid-ing education through the
media while making an effort to equip the peripheral healthfacilities with drugs, equipment, and
personnel to enhance their credibility (Abraham etal. 2015)
• In summary, this study described social health insurance patient behavior in the back-referral
program at The Fatmawati National Vertical Hospital influenced by patientknowledge and
responsiveness of hospital worker. Providing back-referral program education through the
media while making an effort to equip the primary health carefacilities with drugs, equipment,
and personnel to improve the primary health care, willsolve the problem of inefficiency back-
referral program.

Factors influencing two-way referral between hospitals and the community in China: A system
dynamics simulation model https://journals.sagepub.com/doi/epub/10.1177/0037549717741349 :

Nah ini menurut gw salah satu penelitian yang lumayan dalam ngebahas faktor angka referral dan
referral back di China. Mereka ngebedah faktor-faktor sebab akibatnya di casual loop diagram yang
menurut gw cukup mirip dengan konteks di Indonesia. Menurut penelitian ini, untuk ningkatin angka
referral dan referral back itu harus dilakukan dua hal: investasi di Community Health System
(CHS/semacam Puskesmas) – investasi bisa capacity building SDMnya juga untuk memperkecil gap
fasilitas antara Puskesmas dan RS – dan meningkatkan kompensasi biaya medis.
• Casual loop diagram of two-way referral between hospitals and CHSs in China.
• The simulated intervention results showed that increases in the investments in CHSs and medical
insurance compensation level of CHSs benefit two-way referral. Although the policy of increasing
investments in CHSs showed limited benefit compared with money saved by patients being
referred back to CHSs according to cost–benefit analysis, it will significantly improve the medical
technology level of CHSs that lead to an increase in the number of patients that visit CHSs and
are referred back to CHSs. In the existing system structure, referral between hospitals and CHSs
remain relatively low; people are unwilling to transfer from hospitals to CHSs, which in turn
impairs the function of CHSs and broadens the technological gap between hospitals and CHSs. To
solve this problem, the government would be wise to invest more money in CHSs.55
• Patients were primarily unwilling to be referred from hospitals to CHSs because of the large gap
in medical technology between hospitals and CHSs, suggesting that actions should be taken to
bridge this gap. Although healthcare workers in CHSs have already gained widespread
acceptance in many countries,56 general physicians still require continuing
education.57 Communication between general physicians in CHSs and specialists in hospitals is
also helpful for patient-care feedback and has a positive effect on referral and cooperation
between primary-care physicians and specialists.58 China’s medical reform in 2009 emphasized
the training and education of medical staff working in CHSs to achieve, as soon as possible, the
goal of having staff in CHSs to include qualified GPs and to facilitate the communication between
CHSs and hospitals. CHSs should be provided with more funding, better technology, and more
staff, and be equipped with unused hospital resources under governmental guidance. In this
way, the imbalanced resource allocation could be rectified and CHS functioning could be
improved.
• Medical costs were also a major factor that patients considered when seeking medical services.
To promote two-way referral between hospitals and CHSs, widening the disparity in medical
insurance compensation level and medical costs between CHSs and hospitals might be suitable.
As was found regarding the effects of changes in the coverage of medical insurance in CHSs on
emergency department utilization,59 improving the medical insurance compensation level in
CHSs would likely facilitate referral from hospitals to CHSs.
Predictors of referral behaviour and intention amongst physicians in a medical consortium based on
the theory of planned behaviour: a cross-sectional study in China
https://www.frontiersin.org/articles/10.3389/fpubh.2023.1159207/full

Lagi-lagi ini penelitian konteksnya di China. Mereka neliti faktor yang pengaruhi keputusan referral dari
dokter karena dari seluruh dokter yang mau merujuk, lebih dari 1/3 itu ngga benar-benar merealisasikan
merujuknya karena subjektifitas dari dokternya. Karna itu, untuk mengubahnya, mereka rekomendasi
untuk buat panduan kriteria rujukan yang jelas juga sharing ingormation antar faskes untuk ngebantu
dokter memahami kondisi pasiennya.

• Strategies to strengthen subjective norms regarding referrals should focus on developing a

favourable culture for patient referral. On the one hand, sharing and disclosure of information
related to referrals are alternatives to support and supervise referrals of patients (65). An
important approach to strengthen subjective norms is to enhance the perceived pressure from
leaders and colleagues. Sharing information related to referrals could promote sharing of
experiences and opinions among physicians. Meanwhile, disclosure of the information related to
referral-based performance evaluation by institutions could virtually convey the leaders’ views
on referral to physicians and promote inter-group competitions. On the other hand, considering
the lack of compulsory gatekeepers and a patient’s freedom to choose medical institutions in
China, substantial effort is required to increase patients’ referral willingness. One of the most
widely reported predictors of patients’ downward referral interest is the treatment effect of
primary healthcare institutions (2). Participants who evaluated a better treatment effect in
primary healthcare institutions were more willing to be referred to these institutions. According
to a study in Hubei Province, China, the primary healthcare system is qualified as a healthcare
gatekeeper for patients, especially for those with noncommunicable diseases (66). Therefore,
the managers in medical consortia can first pilot the referral of patients with noncommunicable
diseases by promoting their interests in two-way referrals (67).
• Considering perceived behavioural control, medical consortia managers should pay attention to
the referral system and its operations. On the one hand, detailed and feasible guidelines on
referral criteria and related training are essential to increase physicians’ intention to refer
patients. On the other hand, referral management systems allowing for information sharing can
improve the efficiency of physicians’ referral and significantly improve continuous care delivery
for patients (68).
• Majority of physicians intended to refer patients to the county medical consortium, but only a
few referred the patients. We provide supportive evidence that physicians’ referral behaviour in
Chinese county hospitals was influenced by intention, subjective norms, and perceived
behaviour control instead of attitudes.