BACKGROUND & AIMS: :Skyrocketing costs and the uneven quality of patient care challenge the US health care system. Some health insurance companies are exploring patient-centered medical homes as a way to change incentives and transform the health care delivery system by increasing primary care providers' accountability for care coordination and outcomes. Horizon Healthcare Services, Inc., New Jersey's oldest and largest health insurance company, developed medical home programs that include financial incentives with essential support tools. Our experience in implementing and evaluating various approaches indicates that medical homes require intensive and targeted patient care coordination supported by committed primary care leadership, as well as new payment structures that include a monthly care coordination fee and outcome-based payments. Our experience also indicates that considerable nonmonetary support-such as an education program for population care coordinators, a medical home guide that offers effective ways to transform a practice into a medical home, and useful data sharing-are needed to improve the quality of care and reduce costs.

背景与目标： : 飞涨的成本和参差不齐的患者护理质量挑战了美国的医疗保健系统。一些健康保险公司正在探索以患者为中心的医疗之家，以通过增加初级保健提供者对护理协调和结果的责任感来改变激励措施并改变医疗保健提供系统。新泽西州历史最悠久，规模最大的健康保险公司Horizon Healthcare Services，inc.制定了医疗之家计划，其中包括财务激励措施和基本支持工具。我们在实施和评估各种方法方面的经验表明，医疗之家需要由承诺的初级保健领导支持的强化和有针对性的患者护理协调，以及包括每月护理协调费和基于结果的付款的新付款结构。我们的经验还表明，需要大量的非金钱支持，例如针对人口护理协调员的教育计划，提供将实践转变为医疗之家的有效方法的医疗之家指南以及有用的数据共享，以提高护理质量并降低成本。

BACKGROUND & AIMS: BACKGROUND:Launched in January 2011, the prospective payment system (PPS) for the US Medicare End-Stage Renal Disease Program bundled payment for services previously reimbursed independently. Small dialysis organizations may be particularly susceptible to the financial implications of the PPS. The ongoing Study to Evaluate the Prospective Payment System Impact on Small Dialysis Organizations (STEPPS) was designed to describe trends in care and outcomes over the period of PPS implementation. This report details early results between October 2010 and June 2011. STUDY DESIGN:Prospective observational cohort study of patients from a sample of 51 small dialysis organizations. SETTING & PARTICIPANTS:1,873 adult hemodialysis and peritoneal dialysis patients. OUTCOMES:Secular trends in processes of care, anemia, metabolic bone disease management, and red blood cell transfusions. MEASUREMENTS:Facility-level data are collected quarterly. Patient characteristics were collected at enrollment and scheduled intervals thereafter. Clinical outcomes are collected on an ongoing basis. RESULTS:Over time, no significant changes were observed in patient to staff ratios. There was a temporal trend toward greater use of peritoneal dialysis (from 2.4% to 3.6%; P = 0.09). Use of cinacalcet, phosphate binders, and oral vitamin D increased; intravenous (IV) vitamin D use decreased (P for trend for all <0.001). Parathyroid hormone levels increased (from 273 to 324 pg/dL; P < 0.001). Erythropoiesis-stimulating agent doses decreased (P < 0.001 for IV epoetin alfa and IV darbepoetin alfa), particularly high doses. Mean hemoglobin levels decreased (P < 0.001), the percentage of patients with hemoglobin levels <10 g/dL increased (from 12.7% to 16.8%), and transfusion rates increased (from 14.3 to 19.6/100 person-years; P = 0.1). Changes in anemia management were more pronounced for African American patients. LIMITATIONS:Limited data were available for the prebundle period. Secular trends may be subject to the ecologic fallacy and are not causal in nature. CONCLUSIONS:In the period after PPS implementation, IV vitamin D use decreased, use of oral therapies for metabolic bone disease increased, erythropoiesis-stimulating agent use and hemoglobin levels decreased, and transfusion rates increased numerically.

背景与目标：

BACKGROUND & AIMS: BACKGROUND:The Comprehensive Care for Joint Replacement (CJR) model provides bundled payments for in-hospital care and care within 90 days following discharge for Medicare beneficiaries undergoing lower-extremity joint replacement involving the hip, knee, or ankle (total hip arthroplasty, total knee arthroplasty, or total ankle arthroplasty [TAA]). The study hypothesis was that patient comorbidities are associated with readmissions, emergency department (ED) utilization, and subspecialist wound-healing consultation, which are examples of costly contributors to postoperative health-care spending. METHODS:The medical records for 1,024 patients undergoing TAAs between June 2007 and December 2016 at a single academic center in the southeastern United States were reviewed for the outcomes of readmissions, ED visitations, and subspecialist wound-healing consultation within the 90-day post-discharge period. All patients undergoing TAA (n = 1,365) were eligible. Of the 1,037 patients who consented to participation in the study and underwent TAA, 1,024 (98.7%) completed the study. Medical comorbidities according to the Elixhauser and Charlson-Deyo comorbidity indices that were present prior to TAA were recorded. Univariate and multivariable tests of significance were used to relate patient and operative characteristics to outcomes. RESULTS:Four hundred and ninety-six (48.4%) of the 1,024 patients were female, and 964 (94.1%) were white/Caucasian, with an average age (and standard deviation) of 63 ± 10.5 years. Hypertension, obesity, solid tumor, depression, rheumatic disease, cardiac arrhythmia, hypothyroidism, diabetes mellitus, and chronic pulmonary disease had a prevalence of >10%. Fifty-three (5.2%) of the 1,024 patients were readmitted for any cause. Thirty-six (3.5%) of the 1,024 returned to the ED but were not admitted to the hospital. Readmission or ED visitation was most commonly for a wound complication, followed by deep venous thrombosis (DVT) and pulmonary embolism (PE) evaluation, while urgent medical evaluations composed the majority of non-TAA-related ED visitations. No patient comorbidities were significantly associated with 90-day readmission, ED visitation, or wound complications in multivariable models. CONCLUSIONS:Patient comorbidities were not associated with 90-day hospital readmissions or ED visitation for patients undergoing TAA. Readmissions were dominated by evaluation of wound compromise as well as DVT and PE. These data suggest that there may be considerable differences between TAA and total hip arthroplasty or total knee arthroplasty that cause surgeons to question the inclusion of TAA in CJR bundled payment models. LEVEL OF EVIDENCE:Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

背景与目标：

BACKGROUND & AIMS: :Despite the growing interest in conservation approaches that include payments for environmental services (PES), few evaluations of the influence of such interventions on behaviors of individuals have been conducted. We used self-reported changes in six legal and illegal forest-use behaviors to investigate the way in which a PES for biodiversity conservation intervention in Menabe, Madagascar, influenced behavior. Individuals (n =864) from eight intervention communities and five control communities answered questions on their forest-use behaviors before and after the intervention began, as well as on their reasons for changing and their attitudes to various institutions. The payments had little impact on individuals' reported decisions to change behaviors, but it had a strong impact on individuals' attitudes. Payments appeared to legitimize monitoring of behaviors by the implementing nongovernmental organization (NGO), but did not act as a behavioral driver in their own right. Although there were no clear differences between changes in behaviors in the intervention and control communities, the intervention did influence motivations for change. Fear of local forest associations and the implementing NGO were strong motivators for changing behavior in communities with the PES intervention, whereas fear of the national government was the main reason given for change in control communities. Behavioral changes were most stable where fear of local organizations motivated the change. Our results highlight the interactions between different incentives people face when making behavioral decisions and the importance of considering the full range of incentives when designing community-based PES interventions.

背景与目标： : 尽管人们对包括环境服务付款 (PES) 在内的保护方法越来越感兴趣，但很少评估此类干预措施对个人行为的影响。我们使用自我报告的六种合法和非法森林利用行为的变化来调查马达加斯加Menabe进行生物多样性保护干预的PES影响行为的方式。来自八个干预社区和五个控制社区的个人 (n = 864) 回答了有关干预开始之前和之后的森林利用行为以及他们改变的原因和对各种机构的态度的问题。付款对个人报告的改变行为的决定影响不大，但对个人的态度有很大影响。付款似乎使实施非政府组织 (NGO) 对行为的监视合法化，但本身并没有充当行为驱动因素。尽管干预和控制社区的行为变化之间没有明显差异，但干预确实影响了变化的动机。对当地森林协会和实施非政府组织的恐惧是在PES干预下改变社区行为的强烈动机，而对国家政府的恐惧是控制社区变化的主要原因。在对当地组织的恐惧促使这种变化的情况下，行为变化最为稳定。我们的结果强调了人们在做出行为决策时面临的不同激励措施之间的相互作用，以及在设计基于社区的PES干预措施时考虑所有激励措施的重要性。

BACKGROUND & AIMS: :England, France, Germany, the Netherlands, and Sweden spend less as a share of gross domestic product on hospital care than the United States while delivering high-quality services. All five European countries have hospital payment systems based on diagnosis-related groups (DRGs) that classify patients of similar clinical characteristics and comparable costs. Inspired by Medicare's inpatient prospective payment system, which originated the use of DRGs, European DRG systems have implemented different design options and are generally more detailed than Medicare's system, to better distinguish among patients with less and more complex conditions. Incentives to treat more cases are often counterbalanced by volume ceilings in European DRG systems. European payments are usually broader in scope than those in the United States, including physician salaries and readmissions. These European systems, discussed in more detail in the article, suggest potential innovations for reforming DRG-based hospital payment in the United States.

背景与目标： : 在提供高质量服务的同时，英国，法国，德国，荷兰和瑞典在医院护理上的支出占国内生产总值的比例低于美国。所有五个欧洲国家都有基于诊断相关组 (drg) 的医院支付系统，该系统对具有相似临床特征和可比费用的患者进行分类。受Medicare的住院患者预期支付系统的启发，该系统起源于DRGs的使用，欧洲DRG系统实施了不同的设计选项，并且通常比Medicare的系统更详细，以更好地区分病情较少和较复杂的患者。在欧洲DRG系统中，处理更多病例的动机通常会被数量上限所抵消。欧洲的付款范围通常比美国的范围更广，包括医生的薪水和再入院。本文将详细讨论这些欧洲系统，提出了改革美国基于DRG的医院支付的潜在创新。

BACKGROUND & AIMS: :Third-party reimbursement (TPR) has emerged as a crucial issue for dietetics in the past decade. To investigate the level of TPR being obtained by individuals receiving nutrition services from registered dietitians in ambulatory settings, the Connecticut Nutrition Services Payment Systems (NSPS) Committee conducted an audit. Sixty survey packets were distributed to consulting dietitians in private practice and to dietitians in outpatient nutrition clinics. Twenty dietitians participated in the audit process, providing 99 client responses to the survey. Sixty-seven percent of clients submitted the charges for nutrition services to their insurance companies, but only 17% received reimbursement for the claims submitted. This audit process raised the level of awareness of the state membership regarding the need to aggressively pursue TPR for nutrition services at all levels, and it provided a model for dietitians to use to conduct periodic audits and assess TPR being received by their clients.

背景与目标： : 在过去的十年中，第三方报销 (TPR) 已成为营养学的关键问题。为了调查在门诊环境中接受注册营养师营养服务的个人获得的TPR水平，康涅狄格州营养服务支付系统 (NSPS) 委员会进行了审核。向私人执业的营养师咨询和门诊营养诊所的营养师分发了60个调查包。20名营养师参与了审计过程，为调查提供了99份客户回复。7% 的客户向其保险公司提交了营养服务费用，但只有17% 收到了所提交索赔的补偿。这一审计过程提高了国家成员对需要积极追求各级营养服务的TPR的认识水平，并为营养师提供了一个模型，用于进行定期审计和评估客户收到的TPR。

BACKGROUND & AIMS: :Research was undertaken to determine the effects of hospital ownership, location, and Medicare's prospective payment system (PPS) on inpatient uncompensated care. A nonequivalent group design was used with repeated measures of uncompensated care (UNCC) on 137 system hospitals taken pre- and post-PPS. Investor-owned system hospitals demonstrated the largest increase in UNCC (37 percent) under the PPS. Results suggest that not-for-profit and investor-owned system hospitals are becoming more similar in levels of uncompensated care provided and that the PPS has had a negative effect on rural hospital profitability.

背景与目标： : 进行了研究，以确定医院所有权，位置和Medicare的预期支付系统 (PPS) 对住院患者无偿护理的影响。在PPS前后采取的137系统医院中，使用了非等效的组设计，并重复进行了无补偿护理 (UNCC)。投资者拥有的系统医院在PPS下显示出最大的UNCC (37%) 增长。结果表明，非营利性和投资者拥有的系统医院在提供的无偿护理水平上变得越来越相似，PPS对农村医院的盈利能力产生了负面影响。

BACKGROUND & AIMS: PURPOSE:Efforts to curb the rising costs of cancer care while improving quality include alternative payment models (APMs), which offer incentives to reduce avoidable spending and provide high-quality and cost-efficient care. The impact of proposed APMs has not been quantified in real-world practice. In this study, we evaluated ASCO's Patient-Centered Oncology Payment (PCOP) model in existing fee-for-service (FFS) Medicare beneficiaries to understand the magnitude of potential cost savings. MATERIALS AND METHODS:SEER-Medicare data were used to identify women with advanced ovarian cancer diagnosed between 2000 and 2012 who either (1) underwent primary debulking surgery followed by chemotherapy or (2) received neoadjuvant chemotherapy followed by surgery. Medicare payments in each cohort were used to compare FFS and PCOP and to estimate the potential for cost savings across health care services received, including outpatient emergency department visits, hospitalizations, and imaging. RESULTS:Three thousand seven hundred seventy-seven primary debulking surgery and 866 neoadjuvant chemotherapy patients were included in the study, with mean total costs of $75,433 and $95,138 in 2016 US$, respectively Most costs were related to chemotherapy or hospitalization. Additional PCOP-related payments would be offset if hospitalizations could be reduced by 11.6% or imaging claims by 88%. CONCLUSION:APMs have the potential to reduce costs of current FFS reimbursement via either a large reduction in imaging or a modest reduction in hospitalizations during treatment of ovarian cancer. PCOP is a reasonable payment structure for oncologists if the additional payments can provide the necessary resources to invest in improved coordination of care.

背景与目标：

BACKGROUND & AIMS: :We examined the effects of Resource-based Relative Value Scale (RBRVS)- and physician diagnosis-related groups (MDDRG)-based payment for anesthesiology services related to surgery by simulating these physician payment reform options. We merged Medicare Part A (hospital) and Part B (anesthesiology) payment data for 7,770 patients for the MDDRG analysis and examined 10,431 surgical procedures for the RBRVS analysis within 27 diagnosis-related groups (DRGs) during the second half of 1986 in 16 hospitals representing different geographic regions, bed size, and teaching status. Assuming budget neutrality (i.e., constant total expenditure for anesthesiology services) and using the proposed methodologies, we simulated RBRVS and MDDRG payments and compared them to current payments for anesthesiology services. Individual surgical procedures demonstrated a two- to more than four-fold variation in duration, accompanied by a similar variation in anesthesiology payments. Within DRGs, there was a three- to ten-fold variation in duration, and a two- to seven-fold variation in anesthesiology payments. Anesthesiology time was highly correlated with surgical time (r = 0.86-0.96). Compared to the current system, RBRVS and MDDRG systems were associated with systematic variations in payments, such that on average, on each case, anesthesiologists practicing in rural and nonteaching hospitals would gain, whereas those in urban or suburban and teaching facilities would lose. After adjusting for complexity of procedure, the distribution of payment gains and losses was a function of duration of surgery, which is not influenced by the anethesiologist. Longer cases of a given surgical procedure result in payment decreases. The results document the importance of retaining a time factor in the payment methodology for anesthesiology services to maintain equitable payment across practice settings--an objective of physician payment reform.

背景与目标： : 我们通过模拟这些医生支付改革方案，研究了基于资源的相对价值量表 (RBRVS) 和基于医生诊断相关组 (MDDRG) 的支付对与手术相关的麻醉学服务的影响。我们合并了用于MDDRG分析的7,770名患者的Medicare A部分 (医院) 和B部分 (麻醉学) 支付数据，并在下半年1986年在代表不同地理区域的16家医院的27个诊断相关组 (drg) 中检查了RBRVS分析的10,431手术程序，和教学状况。假设预算中立 (即麻醉学服务的总支出恒定) 并使用建议的方法，我们模拟了rbrv和MDDRG付款，并将其与麻醉学服务的当前付款进行了比较。单个外科手术的持续时间显示出两到四倍以上的变化，伴随着麻醉学付款的类似变化。在DRGs中，持续时间变化为3到10倍，麻醉学付款变化为2到7倍。麻醉时间与手术时间高度相关 (r = 0.86-0.96)。与目前的系统相比，RBRVS和MDDRG系统与支付的系统性差异相关，因此平均而言，在每种情况下，在农村和非教学医院执业的麻醉师都会受益，而在城市或郊区和教学设施的麻醉师则会流失。在调整了手术的复杂性之后，付款损益的分布是手术持续时间的函数，不受外科医生的影响。给定手术程序的较长情况会导致付款减少。结果表明，在麻醉学服务的支付方法中保留时间因素以维持整个执业环境的公平支付的重要性-这是医生支付改革的目标。

BACKGROUND & AIMS: BACKGROUND:Much attention has been paid to improving the care of patients with cardiovascular disease by focusing attention on delivery system redesign and payment reforms that encompass the healthcare spectrum, from an acute episode to maintenance of care. However, 1 area of cardiovascular disease care that has received little attention in the advancement of quality is cardiac rehabilitation (CR), a comprehensive secondary prevention program that is significantly underused despite evidence-based guidelines that recommending its use. PURPOSE:The purpose of this article was to analyze the applicability of 2 payment and reimbursement models-pay-for-performance and bundled payments for episodes of care--that can promote the use of CR. CONCLUSIONS:We conclude that a payment model combining elements of both pay-for-performance and episodes of care would increase the use of CR, which would both improve quality and increase efficiency in cardiac care. Specific elements would need to be clearly defined, however, including: (a) how an episode is defined, (b) how to hold providers accountable for the care they provider, (c) how to encourage participation among CR providers, and (d) how to determine an equitable distribution of payment. CLINICAL IMPLICATIONS:Demonstrations testing new payment models must be implemented to generate empirical evidence that a melded pay-for-performance and episode-based care payment model will improve quality and efficiency.

背景与目标：

BACKGROUND & AIMS: OBJECTIVE:To examine changes in postacute care (PAC) use during the initial Medicare payment reforms enacted by the Balanced Budget Act of 1997. DATA SOURCES:We used claims data from the 5 percent Medicare beneficiary sample in 1996, 1998, and 2000. Linked data from the Denominator file, Provider of Service file, and Area Resource File provided additional patient, hospital, and market-area characteristics. STUDY DESIGN:Six disease groups with high PAC use were selected for analysis. We used multinomial logit regression to examine how PAC use differed by year of service, controlling for patient, hospital, and market-area characteristics. PRINCIPAL FINDINGS:There were major changes in PAC use, and a portion of services shifted to settings where reimbursement remained cost-based. During the first reform, the home health agency interim payment system, home health use decreased consistently across disease groups. This decrease was accompanied by increased use in skilled nursing facilities (SNFs). Following the implementation of the prospective payment system for SNFs, the use of inpatient rehabilitation facilities increased. CONCLUSIONS:The shift in usage among settings occurred in two stages that corresponded to the timing of payment reforms for home health agencies and SNFs. Evidence strongly suggests the substitutability between PAC settings. Financial incentives, in addition to clinical needs and individual preferences, play a major role in PAC use.

背景与目标：

BACKGROUND & AIMS: :The Tax Cuts and Jobs Act (TCJA) eliminated the ACA's "shared responsibility payment," which penalized those who failed to comply with the requirement to purchase health insurance. In this article the authors explain efforts in several states to respond to this change by adopting individual health insurance mandates at the state level. Although there are good reasons to think that states may be reluctant to consider establishing their own mandates, New Jersey, the District of Columbia, and Vermont quickly joined Massachusetts in establishing such measures in 2018. In 2019 California and Rhode Island enacted state-level mandates. Four other states-Maryland, Connecticut, Hawaii, and Washington-formally considered mandates but have not enacted them. The authors compare the policy debates among these states and one other state, New York, which has not seen a legislative proposal for a mandate despite its strong support for the ACA. Their analysis explores the dynamics within the US federal system when a key component of a complex and politically salient national initiative is eliminated and states are left with many policy, political, and administrative questions of what to do next.

背景与目标： : 《减税和就业法案》 (TCJA) 取消了ACA的 “分担责任付款”，该付款对那些不遵守购买健康保险要求的人进行了处罚。在本文中，作者解释了几个州通过在州一级采用个人健康保险授权来应对这一变化的努力。尽管有充分的理由认为各州可能不愿考虑建立自己的任务，但新泽西州，哥伦比亚特区和佛蒙特州迅速加入马萨诸塞州，2018年制定了此类措施。2019年，加利福尼亚州和罗德岛州颁布了州级授权。其他四个州-马里兰州，康涅狄格州，夏威夷州和华盛顿州-正式考虑了授权，但尚未颁布。作者比较了这些州和另一个州 (纽约州) 之间的政策辩论，尽管纽约州大力支持ACA，但纽约州尚未看到授权的立法提案。他们的分析探讨了当复杂且具有政治意义的国家倡议的关键组成部分被消除时，美国联邦系统内的动态，各州面临着下一步要做的许多政策，政治和行政问题。

BACKGROUND & AIMS: BACKGROUND:Acute 24-h detoxification services (detox) are necessary but insufficient for many individuals working towards long-term recovery from opiate, alcohol or other drug addiction. Longer engagement in substance use disorder (SUD) treatment can lead to better health outcomes and reductions in overall healthcare costs. Connecting individuals with post-detox SUD treatment and supportive services is a vital next step. Toward this end, the Massachusetts Medicaid program reimburses Community Support Program staff (CSPs) to facilitate these connections. CSP support services are typically paid on a units-of-service basis. As part of a larger study testing health care innovations, one large Medicaid insurer developed a new cadre of workers, called Recovery Support Navigators (RSNs). RSNs performed similar tasks to CSPs but received more extensive training and coaching and were paid an experimental case rate (a flat negotiated reimbursement). This sub-study evaluates the feasibility and impact of case rate payments for RSN services as compared to CSP services paid fee-for-service. METHODS:We analyzed claims data and RSN service data for a segment of the Massachusetts Medicaid population who had more than one detox admission in the last year and also engaged in post-discharge CSP or RSN services. Qualitative data from key informant interviews and Learning Collaboratives with CSPs and RSNs supplemented the findings. RESULTS:Clients receiving RSN services under the case rate utilized the service significantly longer than clients receiving CSP services under unit-based billing. This resulted in a lower average cost per member per month for RSN clients. However, when calculating total SUD treatment costs per member, RSN client costs were 50% higher than CSP client costs. Provider organizations employing RSNs successfully implemented case rate billing. Benefits included allowing time for outreach efforts and training and coaching, activities not paid under the unit-based system. Yet, RSNs identified staffing and larger systems level challenges to consider when using a case rate payment model. CONCLUSIONS:Addiction is a chronic disease that requires long-term investments. Case rate billing offers a promising option for payers and providers as it promotes continued engagement with service providers. To fully realize the benefits of case rate billing, however, larger systems level changes are needed.

背景与目标：

BACKGROUND & AIMS: :We provide an analysis of the effect of physician payment methods on their hospital patients' length of stay and risk of readmission. To do so, we exploit a major reform implemented in Quebec (Canada) in 1999. The Quebec Government introduced an optional mixed compensation (MC) scheme for specialist physicians working in hospital. This scheme combines a fixed per diem with a reduced fee for services provided, as an alternative to the traditional fee-for-service system. We develop a model of a physician's decision to choose the MC scheme. We show that a physician who adopts this system will have incentives to increase his time per clinical service provided. We demonstrate that as long as this effect does not improve his patients' health by more than a critical level, they will stay more days in hospital over the period. At the empirical level, we estimate a model of transition between spells in and out of hospital analog to a difference-in-differences approach. We find that the hospital length of stay of patients treated in departments that opted for the MC system increased on average by 4.2% (0.28 days). However, the risk of readmission to the same department with the same diagnosis does not appear to be overall affected by the reform.

背景与目标： : 我们分析了医生付款方式对其住院患者的住院时间和再入院风险的影响。为此，我们利用在魁北克 (加拿大) 1999年实施的一项重大改革。魁北克政府为在医院工作的专科医生引入了可选的混合补偿 (MC) 计划。该计划将固定的每日津贴与减少的服务费用相结合，以替代传统的按服务收费系统。我们开发了一个医生决定选择MC方案的模型。我们证明，采用该系统的医生将有动力增加其每次提供的临床服务的时间。我们证明，只要这种效果不会使患者的健康状况改善超过临界水平，他们将在此期间住院更多的时间。在经验层面上，我们估计了一个模型，该模型是在医院内和外的法术之间转换为差异差异方法的模型。我们发现，在选择MC系统的部门接受治疗的患者的住院时间平均增加了4.2% (0.28天)。但是，以相同的诊断再次进入同一部门的风险似乎并未受到改革的总体影响。

BACKGROUND & AIMS: BACKGROUND:Tanzania is one of many low income countries committed to universal health coverage and Sustainable Development Goals. Despite these bold goals, there is growing concern that the country could be off-track in meeting these goals. This prompted the Government of Tanzania to look for ways to improve health outcomes in these goals and this led to the introduction of Payment for Performance (P4P) in the health sector. Since the inception of P4P in Tanzania a number of impact, cost-effective and process evaluations have been published with less attention being paid to the experiences of care in this context of P4P, which we argue is important for policy agenda setting. This study therefore explores these experiences from the perspectives of health workers, service users and community health governing committee members. METHODS:A qualitative study design was used to elicit experiences of health workers, health service users and health governing committee members in Rufiji district of the Pwani region in Tanzania. The Payment for Performance pilot was introduced in Pwani region in 2011 and data presented in this article is based on this pilot. A total of 31 in-depth interviews with health workers and 9 focus group discussions with health service users and health governing committee members were conducted. Collected data was analysed through qualitative content analysis. RESULTS:Study informants reported positive experiences with Payment for Performance and highlighted its potential in improving the availability, accessibility, acceptability and quality of care (AAAQ). However, the study found that persistent barriers for achieving AAAQ still exist in the health system of Tanzania and these contribute to negative experiences of care in the context of P4P. CONCLUSION:Our findings suggest that there are a number of positive aspects of care that can be improved by Payment for Performance. However its targeted nature on specific services means that these improvements cannot be generalized at health facility level. Additionally, health workers can go as far as they can in improving health services but some factors that act as barriers as demonstrated in this study are out of their control even in the context of Payment for Performance. In this regard there is need to exercise caution when implementing such initiatives, despite seemingly positive targeted outcomes.

背景与目标：