To the best of our knowledge, this study was the first to examine the impact of the adding incentive for CFDS into PBS for health workers in PHC facilities on their performance of diabetes care. In China, PHC facilities are not the point of first contact, and the residents, including the diabetes patients can choose bypass PHC facilities to seek healthcare at high-level hospitals, which leads to escalating medical costs and low efficiency of whole health system. 23 The implementation of CFDS is a critical way with the intention to change the traditional delivery pattern of China’s PHC services. 24–26 CFDS policy tries to build the multidisciplinary team, construct the stable relationship with patients, and improve the quality of PHC. As PHC facilities have autonomy in designing the detailed assessment criteria and PBS system of themselves, some facilities have started to use incentives to encourage the development of family doctor teams and quality of contracted services. Furthermore, in the pilots of contracted services, the first group of residents to be covered by contracted service all targeted the chronic disease patients, i.e. diabetes patients and high blood-pressure patients. So this study used the opportunity produced by different implementation status in different facilities, chose the outcomes in diabetes management care, and analyzed whether the incentives in PBS system had impacts on the performance of diabetes care, which was measured in the perspective of continuity and coordination of diabetes management care, patients’ utilization of management care and self-reported control of blood glucose. The findings implied that the performance assessment and related incentive may significantly improve process and outcome quality of diabetes management care.
In this study, the key findings are the inclusion of performance of contracted service in the overall performance assessment was associated with the increasing the continuity and coordination of care. Health workers with experience of increasing income because of the performance on contracted service was associated with better coordination in the process of providing care.
Lack of financial incentive for PHC providers is one of the causes for the poor quality of PHC. 27 First, the income level of health workers in PHC facilities was only about 30%-50% of their expected pay level. Second, regarding the payment method, i.e. PBS, the percentage of performance-based bonus on the total income is low, which has limited incentive power to guide the behavior of health worker. 28 The CFDS policy tries to target these problems. The national policy guidance on the c CFDS requires that PHC facilities include the contents of family doctor services into the performance assessment criteria of health workers, and increase the performance-related income to those with more contracted patients and better performance on contracted services. However, the implementation extent of different areas, different facilities, and different family doctor teams is different. In addition, the facility managers are in charge of design for the performance criteria and the performance target for their personnel. These varied situation in implementation process and among different facilities provided good opportunity for us to study the relationship between the addition incentives for contracted services and performance.
The contents of services contracted by family doctor team are designed by policy makers with the intention to solve some challenges for improving the quality of PHC. These challenges are mainly related to the continuity and coordination in PHC, and the coordination between PHC and hospital services.
Firstly, the services provided by PHC facilities inside are commonly fragmented. The medical services provided by physicians and nurses who are primarily paid by social health insurance and patients out-of-pocket payment; while public health services package provided by public health workers who are paid by the National Basic Public Health Service Program funds, with the aims to deliver essential public health services including diabetes management. 29 There is limited coordination in monitoring, performance measurement, or management between the two programs, leading to little workflow interaction or information sharing between the programs. For instance, in diabetes management visits under the National Basic Public Health Service Program, patients can have blood glucose measurement and lifestyle consultations by public health workers, but cannot get prescriptions of hypoglycemic drugs from doctors. 12 Furthermore, the electronic medical record system at PHC facilities is still commonly fragmented, of lack of integrating comprehensive information about individual patients. The resident health management document and medical records in outpatients and inpatients departments are kept by two separate information systems. 12
Secondly, the services provided by different levels of health providers are segmented. Because health system in China is featured by the fragmentation among different tiers of delivery institutions, PHC facilities are not the gatekeeper and patients have a strong preference to bypass the PHC facilities in favor of hospitals. As consequence, the lack of doctors being familiar with the patients and long-term follow-up by the same doctors is a barrier to improve the quality of chronic disease care.
National government policy guidance documents listed some minimum requirements on the package of contracted services, including a series of continuous services from common disease treatment, basic public health services, health management, health education and consultation, to referral to hospitals, etc. The package was mainly intended to solve the above fragmentation problems. The measurement methods for the continuity and coordination of services in this study were designed based on the above service contents defined in these contract family doctor service documents. 8,30 Continuity of care was measured by the awareness of health workers on the treatment and management experience of patients, which is the crucial function of family doctor team, i.e. the continuous caring and long-term relationship between patients and doctor. Coordination of care was measured by the level of information sharing inside the PHC facility and the level of information sharing between PHC facilities and hospitals. Care for chronic disease patients need coordination of screening, treatment, follow-up and management services, which are provided by different cadres in the same facility and different levels of health providers. As the major health manager for the contracted chronic disease patients, the family doctor team and its members have the responsibility in coordinating these services for their patients. Following the national suggestions, the contracted services were finally designed and were dependent on the design and capacity of different facility. 8,30
The finding on the positive relationship between incentive and better performance is consistent with the basic hypothesis that health workers seek to maximize the utility in the selection of work behaviors and the utility of health workers depends on their income and the health status of the contracted patients. 29 The pay-for-performance incentive links quality of care by PHC health workers with their income, which guides PHC health workers seeking to increase their income through providing care of high quality to maximize their utility. Prior empirical studies also have the similar findings that the introduction of pay-for-performance incentive and linking remuneration for general practices to recorded quality of care for diabetes, can increase the provision performance of healthcare services. 15–17
In addition to the positive influence on provision behavior of PHC health workers, this study also find that the incentive is related to positive results on performance measured from the patients’ service utilization and health outcomes. The facility level analysis found that the facilities with higher percentage of health workers whose performance of contracted service had been assessed was associated with higher score on patients’ diabetes care utilization and blood glucose control, and facilities with higher percentage of health workers who had been rewarded because of better performance on contracted service was associated with better patients’ blood glucose control. The results of other studies showed that pay-for-performance incentive was not associated with patient outcomes of diabetes management. For instance, prior studies did not generate evidence supporting a beneficial effect of the pay-for-performance incentive on treatment (e.g., rate of HbA1c test, rate of lipid test, rate of dilated eye exam) and control. 11,15,31 A synthesis result based on high-quality studies on effects of pay-for-performance incentives also found that the pay-for-performance incentive can only have impacts on service procedure outcomes which can totally controlled by health providers, but not on the patient outcome which can only partly controlled by health providers themselves. 32 One possible reason is that our study used the self-reported service utilization and blood glucose control to measure the performance, which probably over-estimated the level of performance. Another possible reason is that the duration of incentives might be different in different studies, and the power of incentives is usually weakened over time, and in China the introduction of family doctor services and relevant incentives for PHC health workers just started. 33
Limitations
This study has several limitations. First, the observational nature of our study limited our ability to draw any causal inference from our findings. The results should not be interpreted as the effect of adding incentive into PBS system on diabetes care processes and outcomes. Rather, the association found in this study underscored the need for research to develop financial incentive policy to improve diabetes management. Second, this study could not consider the duration of the pay-for-performance incentive due to data limitation, which may modify the observed associations between the incentive and diabetes care in our study. Future studies should focus on more rigorous research, including randomized, controlled trials and observational studies with concurrent control groups, to assess the effectiveness of the incentive among the CFDS. And the longitudinal study and ongoing monitoring of the incentive program is critical to determine the effectiveness of incentives and the possible unintended effects on diabetes patients and health care providers. Third, the measurements of blood glucose control were performed by self-administrated method, which may lead to the self-administrated bias. However, the association between the incentive and performance on diabetes management care provide in-depth explanation and reliable support for policy importance to diabetes population in China.