Health care providers need flexibility to be able to respond quickly to meet increased demand in the outbreak, to offer new methods of service delivery and to maintain essential health services for non-COVID-19 conditions. The way in which providers are paid can be an obstacle to these objectives.
We describe some of the ways in which countries are adapting contracting and payment processes to enable providers to respond appropriately taking examples from the COVID-19 Health System Response Monitor unless otherwise noted. The post draws on a short paper from the WHO Barcelona Office for Health Systems Strengthening on key health financing actions countries can take to reduce the adverse effects of the pandemic.
Offering incentives for surge capacity
Health care providers require additional funds to cover the costs of new infrastructure, staff and supplies mobilized in response to the outbreak; rises in the price of essential supplies; and overtime and supplementary payments for staff. Germany pays hospitals €50,000 for each new intensive care unit bed. In the Russian Federation, Moscow’s territorial health insurance fund pays hospitals up to RUB 200,000 for each COVID-19 patient treated. General practitioners in the Netherlands receive an additional €10 for each registered patient and an additional €15 per hour for extra out-of-office care. Ukraine has introduced an hourly payment rate for physicians and other staff directly involved in treating people with COVID-19. Supplementary payments have been promised to staff in several other countries, including France, Germany, Hungary, Italy, Kyrgyzstan, Lithuania, Romania, the Russian Federation, Serbia, Slovenia and the United Kingdom.
Where necessary, countries are developing or simplifying mechanisms to enable existing private capacity for testing and treatment to be used. Ireland has reached agreement with private hospitals to draw on their space, staff and supplies, so that private hospitals are now accessible to the whole population. During the emergency period in Spain, private providers are paid using public provider payment methods and tariffs.
Ensuring stability in provider revenue
In contexts where payment methods reflect service outputs and volume (case-based payment, for example), reductions in the delivery of non-COVID-19 services may lead to a sudden fall in provider revenue. This problem can be averted by front-loading budgets or capitation payments; pre-funding payments that would otherwise come through retrospective reimbursement of claims or patient co-payments; and committing to cover provider costs to prevent bankruptcy.
In the Netherlands, the Minister of Health and health insurers have agreed that no provider will be allowed to go bankrupt; the procedure to be established is under negotiation. Germany has introduced a temporary payment of €560 a day for every unoccupied hospital bed. Hungary is using budgets instead of case-based payment for hospitals during the pandemic. Poland has expanded hospital budgets by five per cent. Belgium, Bosnia and Herzegovina and Latvia are channelling lump sums directly to hospitals. The United Kingdom has written off historic debts held by National Health Service hospitals. Denmark has agreed to accept budget overruns by regional health authorities. Bulgaria, Germany and the Netherlands have entered into agreements with a range of staff unions to compensate providers for lost income.
Changing payment to support innovations in service delivery
Many countries have rapidly adapted the way in which services are delivered in response to COVID-19, including making greater use of home-based care, teleconsultations and other forms of remote delivery. These innovations in service delivery aim to minimize the risk of COVID-19 transmission and maintain the provision of other essential health services.
The health insurance fund in Estonia allows some outpatient visits (specialist consultations, physiotherapy and mental health nurse consultations) to take place remotely, paying for them using the normal tariff. Ireland has negotiated new general practitioner fees for remote consultations for all conditions, not just COVID-19. Germany is adapting provider payment to remunerate new forms of delivery, including new outpatient clinics for people with fever. Luxembourg has introduced a new hourly tariff for outpatient consultations held by any type of doctor in any care setting. In the Netherlands, the Healthcare Authority allows initial patient consultations for non-COVID-19 care to take place by telephone or other remote means. Slovakia offers supplementary payments for remote consultations and has expanded the scope of services that can be provided remotely.
Sarah Thomson, Triin Habicht, Tamás Evetovits