قرارداد پرداخت در یک سیستم مراقبت های بهداشتی پیشگیرانه: چشم اندازی از مدیریت عملیات

We consider a health care system consisting of two noncooperative parties: a health purchaser (payer) and a health provider, where the interaction between the two parties is governed by a payment contract. We determine the contracts that coordinate the health purchaser–health provider relationship; i.e. the contracts that maximize the population's welfare while allowing each entity to optimize its own objective function. We show that under certain conditions (1) when the number of customers for a preventive medical intervention is verifiable, there exists a gate-keeping contract and a set of concave piecewise linear contracts that coordinate the system, and (2) when the number of customers is not verifiable, there exists a contract of bounded linear form and a set of incentive-feasible concave piecewise linear contracts that coordinate the system.

The purchaser–provider relationship is prevalent in health care delivery systems. In this relationship, a health purchaser (e.g. health insurer) and a health provider (e.g. hospital) enter into a contractual agreement in which the health provider agrees to deliver service to the population being covered, and receive reimbursement from the health purchaser according to a prespecified contract (payment system). To design health care payment systems, the interactions between the health purchaser and health provider are usually modeled in principal–agent frameworks (Laffont and Martimort, 2001), where a principal (e.g. health purchaser) delegates a task (e.g. providing medical service to the population) to an agent (e.g. health provider). The health purchaser's problem is then to design a contract that provides sufficient incentives to motivate the health provider toward a set of desired actions, such as, the level of treatment intensity that maximizes the patient's prospective health outcomes. In this paper, we investigate the problem of health care contract design from an Operations Management perspective. We focus on coordinating contracts, which have gained significant attention in the Operations Management literature and have proven to be successful in many real-world applications. These are contacts among entities of a system in which a Nash equilibrium optimizes the global system ( Cachon, 2003, Weng, 1995 and Chick et al., 2008). Here, we extend the notion of coordinating contracts to a preventive health delivery system. In this context, such contracts maximize the population's welfare while allowing both the health purchaser and the health provider to optimize their own objective functions.

An immediate need for health care payment system reform has been stressed by medical scholars (Baron and Cassel, 2008 and Rosenthal, 2008), which is mainly motivated by escalating health care costs, deviations from welfare maximizing medical resource allocations, and imbalance between primary and specialty care. Failure to consider the unique characteristics of health providers (e.g. the provider's cost structure or their population's texture) in designing a payment system will inevitably result in health care inefficiency and inferior social welfare. In this paper, we studied contracts that coordinate the health purchaser–health provider relationship in a preventive health care delivery system. Such contracts allow the health purchaser and the health provider to optimize their objective functions while maximizing the population's welfare. The proposed principal–agent model considers both the problem of moral hazard (hidden action) and asymmetric information (hidden information). In this model, the health provider's decision about the rank of patients to whom the preventive intervention should be administered is not observable (hidden action). The health purchaser may also be unable to observe the number of customers for the medical intervention and the distribution of patient risk categories (hidden information) in the health provider's patient population. When the number of customers for a medical intervention is verifiable by the health purchaser, we show that under certain conditions, there exist a gate-keeping contract and a set of concave piecewise linear contracts that can coordinate the system. When the number of customers is not verifiable, we demonstrated that the widely used fee-for-service payment system does not necessarily coordinate the health purchaser–health provider relationship and the health provider tends to exert an effort level which is less than optimal. Under these settings, the coordinating contract can be of a bounded linear form that reimburses the health provider proportional to the marginal cost of the effort coordinates the health purchaser–health provider relationship, provided that the disutility at the optimal effort level is not too steep. A set of concave piecewise linear contracts can also coordinate the system under demand unverifiability when demand can be discretized. Our model assumes that there is only one medical intervention available for the underlying disease. An immediate extension to our model will be to identify coordinating contracts for cases where more than one medical intervention is available for the disease. In the multiple-intervention paradigm, the coordinating contracts lead the health provider to prescribe the intervention for each patient that results in the best outcome. Also, our model assumes that health providers are not faced with any capacity restrictions in serving their patients. In reality, however, most health providers can only provide the intervention to a limited number of patients during the contractual period. Moreover, our model does not consider possible competition among health providers in attracting the patients. A model that captures the capacity restriction in a health care system or the competition among health providers will be an interesting topic for future research.