Reforming the Portuguese mental health system: an incentive-based approach

Reforming the Portuguese mental health system: an incentive-based approach Background: To promote an effective mental health system, the World Health Organization recommends the involvement of primary care in prevention and treatment of mild diseases and community-based care for serious mental illnesses. Despite a prevalence of lifetime mental health disorders above 30%, Portugal is failing to achieve such recommendations. It was argued that this failure is partly due to inadequate financing mechanisms of mental health care providers. This study proposes an innovative payment model for mental health providers oriented toward incentivising best practices. Methods: We performed a comprehensive review of healthcare providers’ payment schemes and their related incen- tives, and a narrative review of best practices in mental health prevention and care. We designed an alternative pay- ment model, on the basis of the literature, and then we presented it individually, through face-to-face interviews, to a panel of 22 experts with different backgrounds and experience, and from southern and northern Portuguese regions, asking them to comment on the model and provide suggestions. Then, after a first round of interviews, we revised our model, which we presented to experts again for their approval, and provide new suggestions and comments, if deemed necessary. This approach is close to what is generally known as the Delphi technique, although it was not applied in a rigid way. Results: We designed a four-dimension model that focused on (i) the prevention of mental disorders early in life; (ii) the detection of mental disorders in childhood and adolescence; (iii) the implementation of a collaborative stepped care model for depression; and (iv) the integrated community-based care for patients with serious mental illnesses. First, we recommend a bundled payment to primary care practices for the follow-up of children with special needs or at risk under 2 years of age. Second, we propose a pay-for-performance scheme for all primary care practices, based on the number of users under 18 years old who are provided with check-up consultations. Third, we propose a pay- for-performance scheme for all primary care practices, based on the implementation of collaborative stepped care for depression. Finally, we propose a value-based risk-adjusted bundled payment for patients with serious mental illness. Conclusions: The implementation of evidence-based best practices in mental health needs to be supported by adequate payment mechanisms. Our study shows that mental health experts, including decision makers, agree with using economic tools to support best practices, which were also consensual. Keywords: Innovative payment, Mental health, Access, Primary care *Correspondence: jperelman@ensp.unl.pt Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Avenida Padre Cruz, 1600-560 Lisbon, Portugal Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 2 of 10 health in the country. As mentioned in the 2017 evalua- Background tion of the National mental health plan, “so far, Portugal To promote an effective mental health (MH) system, the has no integrated strategy for promotion and preven- World Health Organization (WHO) has made several tion in mental health” (p. 57) [2]. In regard to treatment recommendations, namely, a larger involvement of pri- of moderate depression in PHC, the WHO “Mission to mary healthcare (PHC) in prevention and treatment of assess the progress of the mental health reforms in Por- mild diseases, community-based care for serious men- tugal” mentioned that “unless primary care services tal illnesses (SMI), more integrated care, better access can treat the large minority of people with anxiety and to care, and less discrimination [1]. An evaluation of the depression, specialist services will be paralysed due to the Portuguese mental health plan carried out in 2017 stated demand, unable to focus on people with severe and ongo- that Portugal is failing to achieve such recommendations ing needs” (p. 9) [7]. The same mission observed that “the [2]. The Portuguese mental health system is essentially financing system has created unintentional disincentives centered around inpatient stays and emergency consul- to establish community based services, rewarding hospi- tations, which consume more than 80% of the resources, tal admissions and medical interventions” (p. 9). We fur- coupled with an insufficient provision of community- ther detail the rationale for selecting these dimension as based services [3]. A cross-country comparison has priorities for reforming the payment system. shown that Portugal is below other European countries in terms of development of community-based mental Conceptual background health centers and mental health teams [3]. In the health economics literature, the physician (the These weaknesses are especially worrisome when con - agent) is viewed as making decisions on behalf of the sidering that the prevalence of lifetime mental disorders patient (the principal), because he has more knowledge is above 30% [4], that MH disorders represent 11.7% of and information about diagnoses and treatments. How- disease-adjusted life years lost, and that Portugal expe- ever, the physician is rarely a perfect agent for the patient riences a high prevalence of depression (7.9%), anxiety because he also cares about his own interests (income, (16.5%), impulse disorders (3.5%), and substance abuse leisure time, reputation, etc.). The physician’s objec - (1.6%) in comparison with other European countries [4]. tives of patient well-being and own interest may conflict, Several ambitious and evidence-based plans have been which may result in the physician not always making the proposed over the last decades, but none of them has best decisions for the patient. This agency problem exists been able to convincingly tackle these issues. We docu- because of the impossibility for the patient to adequately mented, in a previous contribution [5], that this failure monitor the physician’s effort and competence due to was partly due to the inadequate payment mechanisms of lack of knowledge and information, and the uncertainty Portuguese MH care providers, which did not encourage surrounding treatments’ outcomes. The fact that patients best practices. Among these mechanisms we highlighted lack information about their MH disease and possi- the volume-based hospital financing system, which does ble treatments is especially acute because of the stigma not encourage the continuity of care or community- surrounding these diseases, which inhibits open dis- based interventions; and the capitation-based model for cussions and information search, while the uncertainty PHC, which favors long lists and short consultations, about treatments’ effectiveness is greater than in other completed by a pay-for-performance (P4P) scheme that clinical domains. These difficulties are amplified by the does not include a single MH indicator. physicians’ own lack of information and knowledge for Based on this perspective this study designs a new pay- MH. For example, a focus group with general practition- ment model for MH care providers in Portugal, focusing ers (GPs), conducted in the UK, observed that “serious on the prevention and detection of MH disorders early mental illness (is) too specialized for routine primary in life, on the treatment of moderate depression in PHC, care and felt they lacked sufficient skills and knowledge” and on the community-based follow-up of SMI. The pre - [8]. Payment mechanisms are of particular importance vention and detection dimensions were first selected as to align physicians’ objectives of patient health and own major issues because of the large burden of mental dis- well-being. ease in Portugal, in comparison with neighbor countries: All traditional payment mechanisms have advantages for example, the 2017 Global Burden of Disease study and drawbacks. The fixed salary avoids incentives to indicates that major depressive disorders represented the discriminate against patients but limits the physicians’ third cause of years lived with disability in Portugal, 40% motivation, introducing a risk of lower quality. Fee-for- than predicted according to the country’s socio-demo- service (FFS) motivates physicians to increase the volume graphic context, while it is the fifth cause in Western of care, but may encourage an excess provision, leading Europe, 10% higher than predicted [6]. The second reason to higher expenditures. Capitation, which reimburses for selection was the extreme weakness of mental public Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 3 of 10 practices on the basis of a list of potential users, pro- Hence, our proposal is more grounded on theoretical motes efficient use of resources but may lead to selecting considerations, adopting the following options: the healthiest users, and to under-provision. The bundled payment, which reimburses providers for treating diag- 1. When there was evidence that a specific service was nosed patients for a given period regardless of services a good practice, we opted to encourage it specifically provided, creates incentives similar to those in capitation, through FFS. except that it does not encourage the selection of healthy 2. Capitation and bundled payments were favored patients because it finances patients with a given disease. because they encourage efficiency, continuity of care, Finally, P4P rewards high quality care but may cultivate a and prevention, but we completed these schemes practice centered exclusively on indicators, and the selec- with P4P in order to limit the risk of under-provision. tion of patients who are more likely to help attain the targets. Let us mention also that FFS is more trusted by Methods patients than other payment models, because they feel Our goal was to create payment mechanisms that that under FFS physicians put the patients’ health and encourage the evidence-based best practices in mental well-being above cost considerations [9]. health, not to define these best practices. This is why we Internationally, alternative reimbursement models have performed a narrative review of the literature, in the four been tested in MH, with limited success. In the United selected domains of action, to identify the best practices States (US), the “Colorado Medicaid Capitation” replaced with proven effectiveness and cost-effectiveness. The the traditional FFS system in 1995, which led to a reduc- option for a non-systematic review was guided by the fact tion in the use of more complex resource-consuming ser- that best practices have long been identified in system - vices and lower expenditures [10], a greater integration atic reviews, and reported in national and international of services [11], consultations replacing inpatient stays guidelines, so that a duplication of this task was not among youths, but no change in prevention [12]. The per deemed necessary. Namely, we used as reference, along case payment system, using Diagnosis Related Groups the study, the book published by the European obser- (DRG), was demonstrated to reduce institutionaliza- vatory on health systems and policies, “Mental health tion of SMI [13] but increased hospital debts, possibly policy and practice across Europe” [16]; the chapters  8 because of the inadequacy of DRG as a classification sys - (promotion of mental health and prevention of mental tem for MH, which are more oriented to short acute stays health disorders), 9 (common problems in primary care), than long-term uncertain ones [14]. In Austria the crea- and 10 (the balance between hospital and community- tion of specific categories for MH allowed hospitals to based mental care) were particularly used as references cover their costs while increasing community-based care. to identify best practices. Finally, in the UK, characterized by an NHS with strong Thereafter, we elaborated payment mechanisms, similarities to the Portuguese one, a payment per activity which we further presented to a large panel of was implemented based on Healthcare Resources Groups experts in the field, who had the opportunity to com - (HRG). However, it was observed that this payment ment on the proposal and make suggestions. We model offered few incentives to MH providers to respond interviewed 22 experts with different backgrounds efficiently to MH needs [15], so that episode-based pay - and experience, and from southern and northern ments were introduced, based on Mental Health Clusters. Portuguese regions. The list of experts included ten These clusters group patients into 21 categories, accord - psychiatrists, four hospital managers with an eco- ing to their needs, and providers are paid a fixed amount nomics background, two psychologists, two nurses, for each treatment period according to the patient’s clus- one hospital manager with a health science back- ter. Jacobs, Chalkley [15] analyzed this payment model, ground, one social assistant, one public health showing a high variation between providers in terms of specialist, and one GP. There were 13 men and 9 costs, treatments, and lengths of stay within clusters, women, and the average experience as professional making the adequate pricing and services of each clus- in the area was 22 years (ranging from 3 to 40) (see ter difficult. These authors concluded that the payment the list in Table 1). should not be abandoned, as it was the most adequate for MH treatment, but that clusters should be revised in order to make them more homogenous. Our study cannot be considered as a qualitative analy- To summarize, theory suggests using payment systems sis in a traditional way, which was beyond our scope and that combine various reimbursement schemes in order to competences. However, we proceeded in a way that is attenuate their weaknesses, while the evidence is poorly close to the Delphi technique, with two rounds, as fol- conclusive about which system functions best in MH. lows. We designed an alternative payment model, on Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 4 of 10 Table 1 Characterization of experts Results We detail here the four dimensions of the proposal, # Profession Sex Experience Region describing the rationale for choosing one as a priority; (years) the type of intervention that we chose to encourage, and 1 Biologist, hospital manager M 11 North why; and the proposed payment mechanism. The final 2 Psychiatrist M 37 South proposals for each dimension are summarized in Table 2. 3 Economist, hospital manager M 18 South 4 Psychiatrist, hospital manager M 36 North Prevention early in life 5 Psychiatrist M 39 North Rationale 6 Nurse F 39 South There is vast evidence that early life adversities affect 7 Psychiatrist F 3 South health in the long run [18]. This is particularly true for 8 Psychologist F 29 South MH. Kessler, McLaughlin [19] estimate that parental MH 9 Public health physician F 4 South disorders, parental criminality, family violence, and phys- 10 Psychiatrist M 3 South ical or sexual abuse, are all related to a higher likelihood 11 Economist, hospital manager F 30 South of MH disorders during childhood, adolescence, and 12 Psychiatrist M 24 South adulthood. Interventions early in life in socially deprived 13 Psychiatrist M 40 South contexts have also been demonstrated to be highly effec - 14 Psychiatrist F 3 South tive in preventing physical and mental illnesses [20]. 15 Nurse M 14 South 16 Psychiatrist M 35 South Intervention 17 Social assistant F 25 South The Portuguese National Plan for Child and Youth Health 18 Economist, hospital manager F 10 North (PNSIJ) acknowledges this point, suggesting that “(…) it 19 Psychologist M 19 South is crucial to evaluate: the adaptation to pregnancy; the 20 Economist M 11 South emotional status of the mother; psychosocial factors” 21 Psychiatrist F 10 North [21]. The text mentions, “The evaluation of the family 22 GP M 42 South dynamic should be a concern for the PHC team at each contact with the child/youth/family. During the first year of life, special attention should be devoted to the emotional status of the mother (due to the risk of post- the basis of the literature, and then we presented it indi- partum depression), referring to the identified cases vidually, through face-to-face interviews, to the panel that may interfere in the child’s development”. The plan of experts, asking them to comment on the model and suggests personalized care for children at risk or spe- provide suggestions. Then, after a first round of indi - cial needs, with a higher frequency of consultations, and vidual interviews, and a collection of highly important the possibility of at-home visits. These visits have been and numerous comments and suggestions, we revised proven to be effective in avoiding MH disorders later in our model, which we presented to experts again for their life [22, 23]. approval, individually, and provide new suggestions and These proposed guidelines seem to represent an comments, if deemed necessary. The consultation rounds adequate response, but their implementation has been occurred between 29 February 2016 and 18 March 2016. limited by the insufficient human resources and by the This approach is indeed close to what is generally absence of a clear signal and compensation to PHC teams known as the Delphi technique, although it was not for whom early prevention of MH disorders should be a applied in a rigid way, and our objective was more about priority. improving our initial model by obtaining new ideas and measuring its feasibility in the Portuguese context, than Payment model to make it fully consensual (contrary to the principle of We propose the creation of a bundled payment to the the Delphi technique, which aims at reaching consensus PHC team for the follow-up of children at risk or with by way of statistical analysis [17]). Indeed, there was no special needs during the two first years of life, with the explicit method to reach a consensus between experts, registration of these children on a central platform, since they were interviewed individually, and had not including information/justification for these children the opportunity to see and comment on other experts’ being considered at risk or with special needs, on the suggestions. This is why our paper also does not display basis of a diagnosis evaluation grid [24]. The presence results of the expert panel. The results of the final model, of a psychologist available for consultation in PHC which derive from our literature review and the inputs practices is also recommended (he/she does not need from experts, are reported. Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 5 of 10 Table 2 Proposed model for MH providers’ financing Dimension Proposal for financing Implementation aspects 1. Prevention early in life Bundled payment to the PC team for the follow-up of children at risk 1. Children registration on a central platform, including information/ or with special needs during the two first years of life justification for being considered at risk or with special needs, using a diagnosis evaluation grid 2. Presence of a psychologist available for consultation in PHC practices 2. Early detection of mental health disorders 1. Adding an indicator in the P4P scheme for PHC practices, namely The diagnosis evaluation grid must be subject to public discussion, the “percentage of users in the key-ages of the PNSIJ who have revised, and subject to a large approval by GPs. The current grid, effectively attended the vigilance consultations, according to the defined by the PNSIJ, includes several mental health recommenda- diagnosis evaluation grid” tions for children and adolescents, related to emotional and behavioral 2. Payment of an additional fee to GPs for each follow-up consultation disorders, psycho-affective and social development, and environment including MH evaluation, using the diagnosis evaluation grid safety 3. Stepped collaborative model for depression 1. Adding an indicator in the P4P scheme for PHC practices, namely 1. Nomination of a reference GP in the PHC team and a reference psy- the “Proportion of users with depression whose condition has been chiatrist in the specialised MH team of catchment area, to enhance the diagnosed with PHQ-9 and treatment has been initiated in the collaboration between primary and specialised care adequate phase of the collaborative stepped care model” 2. Presence of a psychologist available for consultation in PHC practices 2. Payment of a fixed monthly fee to compensate these reference physicians for the extra work 4. Integrated community-based care for SMI patients 1. Implementation of a per period payment, according to which the 1. The payment is attributed to the MH department, which has full hospital receives an annual payment for each patient registered with autonomy and responsibility in managing funds, being the residual SMI, covering all healthcare services claimant 2. The payment is completed by a P4P component 2. The MH department disposes of community-based MH teams, with A bonus (resp. penalty) for the hospitals in the lowest (resp. highest) protocols with PHC practices, residential units, patients and families decile of the distribution in terms of inpatient stays associations, rehabilitation units, nursing homes, social services, and A bonus (resp. penalty) for the hospitals in the lowest (resp. highest) local authorities decile of the distribution in terms of post-discharge consultations up to 30 days after discharge A budget penalty in case the hospital does not contribute and update a national registry of SMI, specifically created within this new pay- ment model Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 6 of 10 Stepped collaborative model for depression to be physically present full time, being preferably part Rationale of a specialized MH team). According to WHO, “PHC is the main pillar support- ing high-quality MH care” [6]. PHC has the capacity to identify and treat MH disorders, refer more severe cases Early detection of mental health disorders to specialists, and carry out prevention and promotion Rationale activities. In particular, the treatment of common men- Kessler, Berglund [25] observed, on the basis of a tal disorders by PHC services has several advantages over cohort, that half of MH disorders (Diagnostic and Sta- the treatment provided by specialized teams, in Portugal: tistical Manual of Mental Disorders, 4th Edition; DSM- (i) easier access related to the wide geographical distri- IV) have their onset before 14 years old, and 75% before bution of PHC practices and the very low co-payments; 24  years old. This study also observed that the median (ii) holistic view of the patient, allowing the treatment of age of onset of anxiety and impulse disorders was comorbidities; and (iii) a more efficient treatment, avoid - 11  years old. However, Burnett-Zeigler, Walton [26] ing the use of more expensive specialized care. concluded that only a third of adolescents attending a PHC consultation receive a psychological evaluation. Intervention According to Gilbody et al. [27], there is strong evidence Intervention that the intervention of PHC in the treatment of depres- PHC practices are the best setting to tackle this issue. sion is effective and cost-effective. We therefore opted to In Portugal, since individuals have easy access to PHC, focus on this disease as a priority, which may be extended due to universal coverage, very low co-payments, and later to other MH diseases. The collaborative stepped wide geographical distribution, the GPs can easily care model has been demonstrated to be an effective reach children and youth. response for the treatment of depression. Thirty-seven Also, the PNSIJ includes guidelines for the evalua- studies measured this effectiveness, showing improve - tion of children and youths, indicating at which ages ments in terms of patient adherence to treatment, qual- they must be evaluated and how. Eleven consultations ity of life, and depression outcomes [28]. The model has are recommended between the first week and the third been implemented differently in various places, namely year of life, and eight consultations between three in the UK [29], the Netherlands [30], the US [31], and and 18  years old. The contents of the MH evaluation Chile [32]. are clearly stated, mentioning affective relationships, Based on the international experience, we suggest the behaviors and disorders, life at home, at childcare, implementation of a model in four stages: and at school, substance abuse, violence, and physical 1st stage Depression diagnosis in PHC, using a pre- abuse. Guidelines are widely available, but are poorly defined symptoms grid (e.g., Patient Health Question - followed because of GPs’ lack of time, and also because naire, PHQ), by the GP or a nurse. the implementation of these guidelines is not clearly 2nd stage Treatment of mild depression in PHC, on the signalled and compensated. In practice, the evaluation basis of self-help, cognitive-behavioral therapy, and phys- of children is essentially centered on physical health, ical exercise, by a specialized MH worker. while adolescents often do not appear at these vigilance 3rd stage Treatment of moderate depression in PHC, consultations. on the basis of medication, psychological interventions, and social support, by the GP or psychologist. 4th stage Treatment of severe, atypical, or psychotic Payment model depression, or with suicide risk, on the basis of medica- We suggest adding an indicator in the P4P scheme for tion, complex psychological interventions, and com- PHC practices, namely the “percentage of users in the bined treatments, by a specialized MH team including a key-ages of the PNSIJ who have effectively attended the psychiatrist. vigilance consultations, according to the diagnosis evalu- The current payment scheme for PHC does not, how - ation grid”. ever, provide incentives for their involvement in MH Given that vigilance consultations are specific ser - care. The capitation payment favors long patient lists, and vices that need to be encouraged, and that MH evalua- thus leads to excess referral and overloading, and short tion is more time consuming, we suggest the payment of consultations, which are not appropriate for MH thera- an additional fee to GPs for each follow-up consultation pies; finally, the P4P scheme does not include a single including MH evaluation, using the diagnosis evaluation indicator related to MH. grid. Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 7 of 10 Payment model • The number and type of patients are contracted at Following Miller, Ross [33], we propose the inclusion the beginning of the year, with the payment being of the following indicator in the P4P scheme for PHC: attributed according to this estimated volume. “Proportion of users with depression whose condition • The payment covers all SMI-related services, namely has been diagnosed with PHQ-9 and treatment has inpatient stays, day care, medications, consultations, been initiated in the adequate phase of the collaborative lab tests, and exams. stepped care model”. • The payment does not cover the non-acute treatment We also suggest nominating a reference GP in the phase, i.e., long-term care services. PHC team and a reference psychiatrist in the special- ized MH team of catchment area, to enhance the col- Also, the participation in the new payment scheme is laboration between primary and specialized care. We conditional on the following: suggest the payment of a fixed monthly fee to com - pensate these physicians for the extra work. The avail - • The payment is attributed to the MH department, ability of psychologists in PHC practices should also be which has full autonomy and responsibility in man- considered. aging funds, being the residual claimant. • The MH department disposes of community-based MH teams, with protocols with PHC practices, resi- Integrated community‑based care for SMI patients dential units, patients and families associations, reha- Rationale bilitation units, nursing homes, social services, and There is substantial evidence suggesting better out - local authorities. comes for SMI when treated in the community, while inpatient stays are associated with poorer health out- Also, the payment includes a P4P component: comes and risk of readmissions [34]. Despite this evi- dence, there are few community-based MH teams in • A bonus (penalty) for the hospitals in the lowest Portugal, while the current hospital financing model (highest) decile of the distribution in terms of inpa- is volume-based, favoring more frequent consultations tient stays. and inpatient stays. • A bonus (penalty) for the hospitals in the lowest (highest) decile of the distribution in terms of post- discharge consultations up to 30 days after discharge. Intervention • A budget penalty in case the hospital does not con- The model to be favored is that of community-based tribute and update a national registry of SMI, specifi - MH teams, which are expected to improve access to care cally created within this new payment model. because of their proximity to patients’ homes and lower stigma; to improve reinsertion because the community- Finally, we suggest an implementation phase of this based setting allows better contacts with social care, fam- new payment scheme, in order to smooth the adaptation, ilies, and employers; to improve follow-up, which leads to collect new data, and evaluate its impact. The implemen - better health outcomes and efficiency through reducing tation will be limited to three hospitals in year 1, six hos- inpatient stays and emergency visits. pitals in year 2, and nine hospitals in year 3. The selection of hospitals for this pilot phase should be made using a random sampling method, from the Payment model universe of Portuguese NHS hospitals with a mental We suggest the implementation of a per period payment, health department from the Lisbon, Coimbra, and Porto according to which the hospital receives an annual pay- regions, where most patients are treated. We suggest ment for each patient registered with SMI, covering all selecting three hospitals used as “treatment group”, and healthcare services. three others as “control group”. Then, the same process The rules for the payment attribution are the following: will be replicated for the three following in year 2, and for the three last in year 3. • Diagnosed with SMI according to the International In their first implementation year, we suggest a 25% Classification of Diseases, 9th Revision, Clinical higher bundled payment, in order to favor the necessary Modification (ICD-9-CM): 292 (drug-induced men - changes in structures and teams. During the first 3 years, tal disorders), 295 (schizophrenic psychosis), 296 data will be collected on resource use, pathologies, and (affective psychosis), 297 (delirium illnesses), or 298 functionality, in order to refine the payment value and (non-organic psychosis). their risk-adjustment for functionality. Afterwards, the Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 8 of 10 new payment model and its values will be designed, and the representativeness of the people we interviewed. the implementation will be extended to all the hospitals In particular, only five (out of 22) experts were from belonging to the Portuguese National Health Service the North region, and none were from the (low-popu- (NHS). lated) Portuguese hinterland. Also, other professionals could have been interviewed, such as community work- Discussion ers, school teachers, or researchers in MH issues. If, as This paper proposes an innovative payment model for the expected, the project creates interest in policy-makers for Portuguese public MH system. This system departs from its implementation in practice, we suggest diffusing the the hypothesis that failures of previous plans, which have proposal through formal channels, and opening a period been largely highlighted in recent national and interna- for public discussion. Second, there is a vast literature on tional evaluations [2, 7], are the result of the neglecting the effects of payment schemes on physicians’ practices, of implementation processes, especially in ensuring that which inspired our model, but the literature is scarce suggested guidelines are properly financed and moti - on the empirical testing of their impact, and even much vated. This is why in this project we focus on a payment scarcer in the field of mental health. This is why we also model, as a means to implement best practices in MH. suggest implementing the model progressively, in order Much has been written about the influence of pay - to measure its effects carefully, before expanding it to the ment models on healthcare providers’ practices [35, 36]. whole country. Finally, we must repeat that all payment Surprisingly, only few studies have addressed the impact schemes have their weaknesses, and even combining of reimbursement schemes in MH. This is why the pro - various models through blended formulas may not suc- posal was mainly based on theoretical and empirical ceed in mitigating them. In particular, we propose to use studies not specifically oriented toward MH, validated in some way the pay-for-performance in all dimensions, by MH experts. This resulted in the view that all pay - which might be associated with excessive focus on incen- ments have serious limitations, so that “payment innova- tivized indicators, crowding-out intrinsic motivation, or tions that blend elements of fee-for-service, capitation, cheating on performance reporting [38]. Although the and case rates can preserve the advantages and attenuate evidence is ambiguous for these adverse effects, they may the disadvantages of each” [37] (p. 150). In other terms, be considered in the implementation process, through it appears clearly that blended payments are the most limiting the weight of the pay-for-performance in the promising option, combining several advantages of vari- physician remuneration. ous payment schemes, in order to diminish their adverse effects. In the meantime, we selected the areas and types Budget impact and other implications of interventions that best correspond to the current As our proposal is largely centered around implementing weaknesses of the Portuguese MH system, and for which new financing mechanisms for MH providers, a major there was more evidence. issue is its sustainability, in a country marked by a rela- This proposal needs to be tested in practice, to confirm tively low GDP per capita compared to other European whether the expected benefits will materialize in practice, countries, and tight public health budgets. Some of our and not be compromised by unexpected adverse effects. suggestions are neutral from a budget viewpoint, as they It should be highlighted that preliminary meetings have merely redistribute money from low performers to high taken place at the Central Administration of the Health performers, in the case of pay-for-performance (dimen- System (ACSS), the Portuguese institution that defines sions 1, 2, and 3), or redistribute the money paid on the and implements the financing of NHS healthcare provid - basis of volume into per-patient payments (dimension ers, in order to implement pilot projects following our 4). However, in dimension 1 we propose a bundled pay- recommendations. This is a promising step because these ment to the PHC team for the follow-up of children at pilot projects include a close evaluation of their effective - risk or with special needs during the first 2 years of life; in ness and cost-effectiveness. Thus, we will be able, in the dimension 2, we suggest the payment of an additional fee following months, to produce outcomes that we expect to GPs for each follow-up consultation; and in dimension to be useful for Portugal and for other mental health sys- 3 the payment of a fixed monthly fee to compensate these tems facing similar difficulties. physicians for the extra work, respectively. Considering an estimated number of 4722 children at risk and prices Limitations of each type of consultations, the annual budget impact Our proposal suffers from some limitations that should of dimension 1 may vary between 1.3 and 2.4 million be mentioned. First, the proposal was presented to and euros. Considering 1,964,862 children in the ages for the validated by only a limited group of experts, selected by follow-up consultations, and a fee of 15 euros per consul- convenience. The choice of a convenience sample limited tation, the annual budget impact of dimension 2 would Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 9 of 10 Nova School of Business and Economics, Universidade NOVA de Lisboa, be of 29.5 million euros. Finally, considering the 857 pri- Campus de Campolide, 1099-032 Lisbon, Portugal. mary care centers and 110 hospitals, and a monthly fee of 124 euros to GPs and specialists, the annual budget Acknowledgements We would like to thank all of the panel experts for their availability and impact of dimension 3 would be of 1.2 million euros. In valuable comments. We are particularly grateful to Dr. Álvaro de Carvalho, other terms, the budget impact of the proposal would be who encouraged and supported the idea of revising the current financing of 33.1 million euros per year, i.e., 0.36% of the total pub- model of the mental health system, and who embraced this project from the beginning. lic health expenditures (9130 million euros in 2017). Note, however, that providers’ payment mechanisms Competing interests are only one among other possible instruments to pro- The authors declare that they have no competing interests. mote best practices in MH, so that it should be accompa- Availability of data and materials nied by investments in community-based care facilities, Not applicable. continuous training and support for GPs, a greater auton- Consent for publication omy for primary care and mental health department Not applicable. managers, and the reinforcement of primary care teams with psychologists. These investments also require an Ethics approval and consent to participate Not applicable. increasing awareness on the part of the population and decision-makers about the burden of MH disease, which Funding financing models cannot achieve. This study was part of the investigation Project 00065SM1, funded by Norway, Iceland, and Liechtenstein, through the EEA grants, and inserted in the pro- gram “Public Health Initiatives”, of ACSS. Conclusion Publisher’s Note The Portuguese MH system suffers from various weak - Springer Nature remains neutral with regard to jurisdictional claims in pub- nesses, and has failed to implement WHO recommen- lished maps and institutional affiliations. dations on best practices. This failure is largely related Received: 29 September 2017 Accepted: 11 May 2018 to inadequate payment and incentives to providers. To overcome this problem, we designed an alternative pay- ment model for primary care and hospitals on the basis of the literature and experts’ consultation. The model References focuses on prevention and detection of diseases early in 1. World Health Organization. Improving health systems and services for mental health. Switzerland: World Health Organization; 2009. life, stepped care collaborative model for depression, and 2. Comissão Técnica de Acompanhamento da Reforma da Saúde Mental. community-based care for SMI. This alternative financ - Relatório da Avaliação do Plano Nacional de Saúde mental 2007–2016 e ing model for mental healthcare providers, aimed at propostas prioritárias para a extensão a 2020. Lisbon: Serviço Nacional de Saúde; 2017. incentivizing best practices, is expected to contribute to a 3. Joint Action on Mental Health and Well-Being. Towards community- better quality of all MH financing systems that are facing based and socially inclusive mental health care: situation analysis and the same challenges as the Portuguese one. recommendations for action. Reykjavík: Joint Action on Mental Health and Well-Being; 2015. 4. Caldas de Almeida J, Xavier M. Estudo epidemiológico de saúde mental. Lisbon: Faculdade de Ciências Médicas—Universidade Nova de Lisboa; Abbreviations ACSS: Central Administration of the Health System; DRG: Diagnosis Related 5. Perelman J, Chaves P, Gago J, Leuschner A, Lourenço A, Mestre R, et al. Group; DSM-IV: Diagnostic and Statistical Manual of Mental Disorders, 4th Edi- Sistema português de saúde mental: avaliação crítica do modelo de tion; FFS: fee-for-service; GP: general practitioner; ICD-9-CM: International Clas- pagamento aos prestadores. Port J Public Health. 2018. https ://doi. sification of Diseases, 9th Revision, Clinical Modification; MH: mental health; org/10.1159/00048 8073. NHS: National Health Service; PHC: primary healthcare; PHQ: Patient Health 6. GBD 2016 Disease and Injury Incidence and Prevalence Collaborators. Questionnaire; PNSIJ: Portuguese National Plan for Child and Youth Health; Global, regional, and national incidence, prevalence, and years lived with P4P: pay-for-performance; SMI: serious mental illness; UK: United Kingdom; US: disability for 328 diseases and injuries for 195 countries, 1990–2016: a United States; WHO: World Health Organization. systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390:1211–59. Authors’ contributions 7. World Health Organization Regional Office for Europe. WHO Mission to JCA launched the idea of revising the current financing model of the mental assess the progress of the mental health reforms in Portugal. Copenha- health system. JP, PC, and MAM performed the analysis. JP and MAM contrib- gen: WHO Regional Office for Europe; 2011. uted in the writing of the manuscript. JCA and JP revised the manuscript. All 8. Lester H, Tritter JQ, Sorohan H. Patients’ and health professionals’ views on authors read and approved the final manuscript. primary care for people with serious mental illness: focus group study. BMJ. 2005;330(7500):1122. Author details 9. Kao AC, Green DC, Zaslavsky AM, Koplan JP, Cleary PD. The relation- Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Avenida ship between method of physician payment and patient trust. JAMA. Padre Cruz, 1600-560 Lisbon, Portugal. Centro de Investigação em Saúde 1998;280(19):1708–14. Publica, Escola Nacional de Saúde Pública, Avenida Padre Cruz, 1600-560 Lis- bon, Portugal. NOVA Medical School, Campus Sant’Ana, Pólo de Investigação, NMS, UNL, Rua do Instituto, Bacteriológico, no 5, 1150-082 Lisbon, Portugal. Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 10 of 10 10. Bloom JR, Tw Hu, Wallace N, Cuffel B, Hausman JW, Sheu ML, et al. Mental 25. 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The role of economic incentives in improving Lisbon: Direção Geral da Saúde; 2013. the quality of mental health care. In: Jones AM, editor. The elgar compan- 22. Peacock S, Konrad S, Watson E, Nickel D, Muhajarine N. Eec ff tiveness of ion to health economics. 2nd ed. Northampton: Edward Elgar Publishing; home visiting programs on child outcomes: a systematic review. BMC 2012. p. 297–306. Public Health. 2013;13(1):1. 36. Rice T. The physician as the patient agent. In: Jones AM, editor. The elgar 23. Olds DL, Holmberg JR, Donelan-McCall N, Luckey DW, Knudtson MD, companion to health economics. 2nd ed. Northampton: Edward Elgar Robinson J. Eec ff ts of home visits by paraprofessionals and by nurses Publishing; 2012. p. 271–80. on children: follow-up of a randomized trial at ages 6 and 9 years. JAMA 37. Robinson JC. Theory and practice in the design of physician payment Pediatr. 2014;168(2):114–21. incentives. Milbank Q. 2001;79(2):149–77. 24. Coordenação Nacional para a Saúde Mental. Recomendações para a 38. Doran T, Maurer KA, Ryan AM. Impact of provider incentives on quality Prática Clínica da Saúde Mental Infantil e Juvenil nos Cuidados de Saúde and value of health care. Annu Rev Public Health. 2017;38:449–65. Primários. Lisboa: Direção Geral da Saúde; 2009. Ready to submit your research ? Choose BMC and benefit from: fast, convenient online submission thorough peer review by experienced researchers in your field rapid publication on acceptance support for research data, including large and complex data types • gold Open Access which fosters wider collaboration and increased citations maximum visibility for your research: over 100M website views per year At BMC, research is always in progress. Learn more biomedcentral.com/submissions http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png International Journal of Mental Health Systems Springer Journals

Reforming the Portuguese mental health system: an incentive-based approach

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Medicine & Public Health; Psychiatry; Clinical Psychology; Health Administration
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Abstract

Background: To promote an effective mental health system, the World Health Organization recommends the involvement of primary care in prevention and treatment of mild diseases and community-based care for serious mental illnesses. Despite a prevalence of lifetime mental health disorders above 30%, Portugal is failing to achieve such recommendations. It was argued that this failure is partly due to inadequate financing mechanisms of mental health care providers. This study proposes an innovative payment model for mental health providers oriented toward incentivising best practices. Methods: We performed a comprehensive review of healthcare providers’ payment schemes and their related incen- tives, and a narrative review of best practices in mental health prevention and care. We designed an alternative pay- ment model, on the basis of the literature, and then we presented it individually, through face-to-face interviews, to a panel of 22 experts with different backgrounds and experience, and from southern and northern Portuguese regions, asking them to comment on the model and provide suggestions. Then, after a first round of interviews, we revised our model, which we presented to experts again for their approval, and provide new suggestions and comments, if deemed necessary. This approach is close to what is generally known as the Delphi technique, although it was not applied in a rigid way. Results: We designed a four-dimension model that focused on (i) the prevention of mental disorders early in life; (ii) the detection of mental disorders in childhood and adolescence; (iii) the implementation of a collaborative stepped care model for depression; and (iv) the integrated community-based care for patients with serious mental illnesses. First, we recommend a bundled payment to primary care practices for the follow-up of children with special needs or at risk under 2 years of age. Second, we propose a pay-for-performance scheme for all primary care practices, based on the number of users under 18 years old who are provided with check-up consultations. Third, we propose a pay- for-performance scheme for all primary care practices, based on the implementation of collaborative stepped care for depression. Finally, we propose a value-based risk-adjusted bundled payment for patients with serious mental illness. Conclusions: The implementation of evidence-based best practices in mental health needs to be supported by adequate payment mechanisms. Our study shows that mental health experts, including decision makers, agree with using economic tools to support best practices, which were also consensual. Keywords: Innovative payment, Mental health, Access, Primary care *Correspondence: jperelman@ensp.unl.pt Escola Nacional de Saúde Pública, Universidade NOVA de Lisboa, Avenida Padre Cruz, 1600-560 Lisbon, Portugal Full list of author information is available at the end of the article © The Author(s) 2018. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creat iveco mmons .org/licen ses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creat iveco mmons .org/ publi cdoma in/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 2 of 10 health in the country. As mentioned in the 2017 evalua- Background tion of the National mental health plan, “so far, Portugal To promote an effective mental health (MH) system, the has no integrated strategy for promotion and preven- World Health Organization (WHO) has made several tion in mental health” (p. 57) [2]. In regard to treatment recommendations, namely, a larger involvement of pri- of moderate depression in PHC, the WHO “Mission to mary healthcare (PHC) in prevention and treatment of assess the progress of the mental health reforms in Por- mild diseases, community-based care for serious men- tugal” mentioned that “unless primary care services tal illnesses (SMI), more integrated care, better access can treat the large minority of people with anxiety and to care, and less discrimination [1]. An evaluation of the depression, specialist services will be paralysed due to the Portuguese mental health plan carried out in 2017 stated demand, unable to focus on people with severe and ongo- that Portugal is failing to achieve such recommendations ing needs” (p. 9) [7]. The same mission observed that “the [2]. The Portuguese mental health system is essentially financing system has created unintentional disincentives centered around inpatient stays and emergency consul- to establish community based services, rewarding hospi- tations, which consume more than 80% of the resources, tal admissions and medical interventions” (p. 9). We fur- coupled with an insufficient provision of community- ther detail the rationale for selecting these dimension as based services [3]. A cross-country comparison has priorities for reforming the payment system. shown that Portugal is below other European countries in terms of development of community-based mental Conceptual background health centers and mental health teams [3]. In the health economics literature, the physician (the These weaknesses are especially worrisome when con - agent) is viewed as making decisions on behalf of the sidering that the prevalence of lifetime mental disorders patient (the principal), because he has more knowledge is above 30% [4], that MH disorders represent 11.7% of and information about diagnoses and treatments. How- disease-adjusted life years lost, and that Portugal expe- ever, the physician is rarely a perfect agent for the patient riences a high prevalence of depression (7.9%), anxiety because he also cares about his own interests (income, (16.5%), impulse disorders (3.5%), and substance abuse leisure time, reputation, etc.). The physician’s objec - (1.6%) in comparison with other European countries [4]. tives of patient well-being and own interest may conflict, Several ambitious and evidence-based plans have been which may result in the physician not always making the proposed over the last decades, but none of them has best decisions for the patient. This agency problem exists been able to convincingly tackle these issues. We docu- because of the impossibility for the patient to adequately mented, in a previous contribution [5], that this failure monitor the physician’s effort and competence due to was partly due to the inadequate payment mechanisms of lack of knowledge and information, and the uncertainty Portuguese MH care providers, which did not encourage surrounding treatments’ outcomes. The fact that patients best practices. Among these mechanisms we highlighted lack information about their MH disease and possi- the volume-based hospital financing system, which does ble treatments is especially acute because of the stigma not encourage the continuity of care or community- surrounding these diseases, which inhibits open dis- based interventions; and the capitation-based model for cussions and information search, while the uncertainty PHC, which favors long lists and short consultations, about treatments’ effectiveness is greater than in other completed by a pay-for-performance (P4P) scheme that clinical domains. These difficulties are amplified by the does not include a single MH indicator. physicians’ own lack of information and knowledge for Based on this perspective this study designs a new pay- MH. For example, a focus group with general practition- ment model for MH care providers in Portugal, focusing ers (GPs), conducted in the UK, observed that “serious on the prevention and detection of MH disorders early mental illness (is) too specialized for routine primary in life, on the treatment of moderate depression in PHC, care and felt they lacked sufficient skills and knowledge” and on the community-based follow-up of SMI. The pre - [8]. Payment mechanisms are of particular importance vention and detection dimensions were first selected as to align physicians’ objectives of patient health and own major issues because of the large burden of mental dis- well-being. ease in Portugal, in comparison with neighbor countries: All traditional payment mechanisms have advantages for example, the 2017 Global Burden of Disease study and drawbacks. The fixed salary avoids incentives to indicates that major depressive disorders represented the discriminate against patients but limits the physicians’ third cause of years lived with disability in Portugal, 40% motivation, introducing a risk of lower quality. Fee-for- than predicted according to the country’s socio-demo- service (FFS) motivates physicians to increase the volume graphic context, while it is the fifth cause in Western of care, but may encourage an excess provision, leading Europe, 10% higher than predicted [6]. The second reason to higher expenditures. Capitation, which reimburses for selection was the extreme weakness of mental public Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 3 of 10 practices on the basis of a list of potential users, pro- Hence, our proposal is more grounded on theoretical motes efficient use of resources but may lead to selecting considerations, adopting the following options: the healthiest users, and to under-provision. The bundled payment, which reimburses providers for treating diag- 1. When there was evidence that a specific service was nosed patients for a given period regardless of services a good practice, we opted to encourage it specifically provided, creates incentives similar to those in capitation, through FFS. except that it does not encourage the selection of healthy 2. Capitation and bundled payments were favored patients because it finances patients with a given disease. because they encourage efficiency, continuity of care, Finally, P4P rewards high quality care but may cultivate a and prevention, but we completed these schemes practice centered exclusively on indicators, and the selec- with P4P in order to limit the risk of under-provision. tion of patients who are more likely to help attain the targets. Let us mention also that FFS is more trusted by Methods patients than other payment models, because they feel Our goal was to create payment mechanisms that that under FFS physicians put the patients’ health and encourage the evidence-based best practices in mental well-being above cost considerations [9]. health, not to define these best practices. This is why we Internationally, alternative reimbursement models have performed a narrative review of the literature, in the four been tested in MH, with limited success. In the United selected domains of action, to identify the best practices States (US), the “Colorado Medicaid Capitation” replaced with proven effectiveness and cost-effectiveness. The the traditional FFS system in 1995, which led to a reduc- option for a non-systematic review was guided by the fact tion in the use of more complex resource-consuming ser- that best practices have long been identified in system - vices and lower expenditures [10], a greater integration atic reviews, and reported in national and international of services [11], consultations replacing inpatient stays guidelines, so that a duplication of this task was not among youths, but no change in prevention [12]. The per deemed necessary. Namely, we used as reference, along case payment system, using Diagnosis Related Groups the study, the book published by the European obser- (DRG), was demonstrated to reduce institutionaliza- vatory on health systems and policies, “Mental health tion of SMI [13] but increased hospital debts, possibly policy and practice across Europe” [16]; the chapters  8 because of the inadequacy of DRG as a classification sys - (promotion of mental health and prevention of mental tem for MH, which are more oriented to short acute stays health disorders), 9 (common problems in primary care), than long-term uncertain ones [14]. In Austria the crea- and 10 (the balance between hospital and community- tion of specific categories for MH allowed hospitals to based mental care) were particularly used as references cover their costs while increasing community-based care. to identify best practices. Finally, in the UK, characterized by an NHS with strong Thereafter, we elaborated payment mechanisms, similarities to the Portuguese one, a payment per activity which we further presented to a large panel of was implemented based on Healthcare Resources Groups experts in the field, who had the opportunity to com - (HRG). However, it was observed that this payment ment on the proposal and make suggestions. We model offered few incentives to MH providers to respond interviewed 22 experts with different backgrounds efficiently to MH needs [15], so that episode-based pay - and experience, and from southern and northern ments were introduced, based on Mental Health Clusters. Portuguese regions. The list of experts included ten These clusters group patients into 21 categories, accord - psychiatrists, four hospital managers with an eco- ing to their needs, and providers are paid a fixed amount nomics background, two psychologists, two nurses, for each treatment period according to the patient’s clus- one hospital manager with a health science back- ter. Jacobs, Chalkley [15] analyzed this payment model, ground, one social assistant, one public health showing a high variation between providers in terms of specialist, and one GP. There were 13 men and 9 costs, treatments, and lengths of stay within clusters, women, and the average experience as professional making the adequate pricing and services of each clus- in the area was 22 years (ranging from 3 to 40) (see ter difficult. These authors concluded that the payment the list in Table 1). should not be abandoned, as it was the most adequate for MH treatment, but that clusters should be revised in order to make them more homogenous. Our study cannot be considered as a qualitative analy- To summarize, theory suggests using payment systems sis in a traditional way, which was beyond our scope and that combine various reimbursement schemes in order to competences. However, we proceeded in a way that is attenuate their weaknesses, while the evidence is poorly close to the Delphi technique, with two rounds, as fol- conclusive about which system functions best in MH. lows. We designed an alternative payment model, on Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 4 of 10 Table 1 Characterization of experts Results We detail here the four dimensions of the proposal, # Profession Sex Experience Region describing the rationale for choosing one as a priority; (years) the type of intervention that we chose to encourage, and 1 Biologist, hospital manager M 11 North why; and the proposed payment mechanism. The final 2 Psychiatrist M 37 South proposals for each dimension are summarized in Table 2. 3 Economist, hospital manager M 18 South 4 Psychiatrist, hospital manager M 36 North Prevention early in life 5 Psychiatrist M 39 North Rationale 6 Nurse F 39 South There is vast evidence that early life adversities affect 7 Psychiatrist F 3 South health in the long run [18]. This is particularly true for 8 Psychologist F 29 South MH. Kessler, McLaughlin [19] estimate that parental MH 9 Public health physician F 4 South disorders, parental criminality, family violence, and phys- 10 Psychiatrist M 3 South ical or sexual abuse, are all related to a higher likelihood 11 Economist, hospital manager F 30 South of MH disorders during childhood, adolescence, and 12 Psychiatrist M 24 South adulthood. Interventions early in life in socially deprived 13 Psychiatrist M 40 South contexts have also been demonstrated to be highly effec - 14 Psychiatrist F 3 South tive in preventing physical and mental illnesses [20]. 15 Nurse M 14 South 16 Psychiatrist M 35 South Intervention 17 Social assistant F 25 South The Portuguese National Plan for Child and Youth Health 18 Economist, hospital manager F 10 North (PNSIJ) acknowledges this point, suggesting that “(…) it 19 Psychologist M 19 South is crucial to evaluate: the adaptation to pregnancy; the 20 Economist M 11 South emotional status of the mother; psychosocial factors” 21 Psychiatrist F 10 North [21]. The text mentions, “The evaluation of the family 22 GP M 42 South dynamic should be a concern for the PHC team at each contact with the child/youth/family. During the first year of life, special attention should be devoted to the emotional status of the mother (due to the risk of post- the basis of the literature, and then we presented it indi- partum depression), referring to the identified cases vidually, through face-to-face interviews, to the panel that may interfere in the child’s development”. The plan of experts, asking them to comment on the model and suggests personalized care for children at risk or spe- provide suggestions. Then, after a first round of indi - cial needs, with a higher frequency of consultations, and vidual interviews, and a collection of highly important the possibility of at-home visits. These visits have been and numerous comments and suggestions, we revised proven to be effective in avoiding MH disorders later in our model, which we presented to experts again for their life [22, 23]. approval, individually, and provide new suggestions and These proposed guidelines seem to represent an comments, if deemed necessary. The consultation rounds adequate response, but their implementation has been occurred between 29 February 2016 and 18 March 2016. limited by the insufficient human resources and by the This approach is indeed close to what is generally absence of a clear signal and compensation to PHC teams known as the Delphi technique, although it was not for whom early prevention of MH disorders should be a applied in a rigid way, and our objective was more about priority. improving our initial model by obtaining new ideas and measuring its feasibility in the Portuguese context, than Payment model to make it fully consensual (contrary to the principle of We propose the creation of a bundled payment to the the Delphi technique, which aims at reaching consensus PHC team for the follow-up of children at risk or with by way of statistical analysis [17]). Indeed, there was no special needs during the two first years of life, with the explicit method to reach a consensus between experts, registration of these children on a central platform, since they were interviewed individually, and had not including information/justification for these children the opportunity to see and comment on other experts’ being considered at risk or with special needs, on the suggestions. This is why our paper also does not display basis of a diagnosis evaluation grid [24]. The presence results of the expert panel. The results of the final model, of a psychologist available for consultation in PHC which derive from our literature review and the inputs practices is also recommended (he/she does not need from experts, are reported. Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 5 of 10 Table 2 Proposed model for MH providers’ financing Dimension Proposal for financing Implementation aspects 1. Prevention early in life Bundled payment to the PC team for the follow-up of children at risk 1. Children registration on a central platform, including information/ or with special needs during the two first years of life justification for being considered at risk or with special needs, using a diagnosis evaluation grid 2. Presence of a psychologist available for consultation in PHC practices 2. Early detection of mental health disorders 1. Adding an indicator in the P4P scheme for PHC practices, namely The diagnosis evaluation grid must be subject to public discussion, the “percentage of users in the key-ages of the PNSIJ who have revised, and subject to a large approval by GPs. The current grid, effectively attended the vigilance consultations, according to the defined by the PNSIJ, includes several mental health recommenda- diagnosis evaluation grid” tions for children and adolescents, related to emotional and behavioral 2. Payment of an additional fee to GPs for each follow-up consultation disorders, psycho-affective and social development, and environment including MH evaluation, using the diagnosis evaluation grid safety 3. Stepped collaborative model for depression 1. Adding an indicator in the P4P scheme for PHC practices, namely 1. Nomination of a reference GP in the PHC team and a reference psy- the “Proportion of users with depression whose condition has been chiatrist in the specialised MH team of catchment area, to enhance the diagnosed with PHQ-9 and treatment has been initiated in the collaboration between primary and specialised care adequate phase of the collaborative stepped care model” 2. Presence of a psychologist available for consultation in PHC practices 2. Payment of a fixed monthly fee to compensate these reference physicians for the extra work 4. Integrated community-based care for SMI patients 1. Implementation of a per period payment, according to which the 1. The payment is attributed to the MH department, which has full hospital receives an annual payment for each patient registered with autonomy and responsibility in managing funds, being the residual SMI, covering all healthcare services claimant 2. The payment is completed by a P4P component 2. The MH department disposes of community-based MH teams, with A bonus (resp. penalty) for the hospitals in the lowest (resp. highest) protocols with PHC practices, residential units, patients and families decile of the distribution in terms of inpatient stays associations, rehabilitation units, nursing homes, social services, and A bonus (resp. penalty) for the hospitals in the lowest (resp. highest) local authorities decile of the distribution in terms of post-discharge consultations up to 30 days after discharge A budget penalty in case the hospital does not contribute and update a national registry of SMI, specifically created within this new pay- ment model Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 6 of 10 Stepped collaborative model for depression to be physically present full time, being preferably part Rationale of a specialized MH team). According to WHO, “PHC is the main pillar support- ing high-quality MH care” [6]. PHC has the capacity to identify and treat MH disorders, refer more severe cases Early detection of mental health disorders to specialists, and carry out prevention and promotion Rationale activities. In particular, the treatment of common men- Kessler, Berglund [25] observed, on the basis of a tal disorders by PHC services has several advantages over cohort, that half of MH disorders (Diagnostic and Sta- the treatment provided by specialized teams, in Portugal: tistical Manual of Mental Disorders, 4th Edition; DSM- (i) easier access related to the wide geographical distri- IV) have their onset before 14 years old, and 75% before bution of PHC practices and the very low co-payments; 24  years old. This study also observed that the median (ii) holistic view of the patient, allowing the treatment of age of onset of anxiety and impulse disorders was comorbidities; and (iii) a more efficient treatment, avoid - 11  years old. However, Burnett-Zeigler, Walton [26] ing the use of more expensive specialized care. concluded that only a third of adolescents attending a PHC consultation receive a psychological evaluation. Intervention According to Gilbody et al. [27], there is strong evidence Intervention that the intervention of PHC in the treatment of depres- PHC practices are the best setting to tackle this issue. sion is effective and cost-effective. We therefore opted to In Portugal, since individuals have easy access to PHC, focus on this disease as a priority, which may be extended due to universal coverage, very low co-payments, and later to other MH diseases. The collaborative stepped wide geographical distribution, the GPs can easily care model has been demonstrated to be an effective reach children and youth. response for the treatment of depression. Thirty-seven Also, the PNSIJ includes guidelines for the evalua- studies measured this effectiveness, showing improve - tion of children and youths, indicating at which ages ments in terms of patient adherence to treatment, qual- they must be evaluated and how. Eleven consultations ity of life, and depression outcomes [28]. The model has are recommended between the first week and the third been implemented differently in various places, namely year of life, and eight consultations between three in the UK [29], the Netherlands [30], the US [31], and and 18  years old. The contents of the MH evaluation Chile [32]. are clearly stated, mentioning affective relationships, Based on the international experience, we suggest the behaviors and disorders, life at home, at childcare, implementation of a model in four stages: and at school, substance abuse, violence, and physical 1st stage Depression diagnosis in PHC, using a pre- abuse. Guidelines are widely available, but are poorly defined symptoms grid (e.g., Patient Health Question - followed because of GPs’ lack of time, and also because naire, PHQ), by the GP or a nurse. the implementation of these guidelines is not clearly 2nd stage Treatment of mild depression in PHC, on the signalled and compensated. In practice, the evaluation basis of self-help, cognitive-behavioral therapy, and phys- of children is essentially centered on physical health, ical exercise, by a specialized MH worker. while adolescents often do not appear at these vigilance 3rd stage Treatment of moderate depression in PHC, consultations. on the basis of medication, psychological interventions, and social support, by the GP or psychologist. 4th stage Treatment of severe, atypical, or psychotic Payment model depression, or with suicide risk, on the basis of medica- We suggest adding an indicator in the P4P scheme for tion, complex psychological interventions, and com- PHC practices, namely the “percentage of users in the bined treatments, by a specialized MH team including a key-ages of the PNSIJ who have effectively attended the psychiatrist. vigilance consultations, according to the diagnosis evalu- The current payment scheme for PHC does not, how - ation grid”. ever, provide incentives for their involvement in MH Given that vigilance consultations are specific ser - care. The capitation payment favors long patient lists, and vices that need to be encouraged, and that MH evalua- thus leads to excess referral and overloading, and short tion is more time consuming, we suggest the payment of consultations, which are not appropriate for MH thera- an additional fee to GPs for each follow-up consultation pies; finally, the P4P scheme does not include a single including MH evaluation, using the diagnosis evaluation indicator related to MH. grid. Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 7 of 10 Payment model • The number and type of patients are contracted at Following Miller, Ross [33], we propose the inclusion the beginning of the year, with the payment being of the following indicator in the P4P scheme for PHC: attributed according to this estimated volume. “Proportion of users with depression whose condition • The payment covers all SMI-related services, namely has been diagnosed with PHQ-9 and treatment has inpatient stays, day care, medications, consultations, been initiated in the adequate phase of the collaborative lab tests, and exams. stepped care model”. • The payment does not cover the non-acute treatment We also suggest nominating a reference GP in the phase, i.e., long-term care services. PHC team and a reference psychiatrist in the special- ized MH team of catchment area, to enhance the col- Also, the participation in the new payment scheme is laboration between primary and specialized care. We conditional on the following: suggest the payment of a fixed monthly fee to com - pensate these physicians for the extra work. The avail - • The payment is attributed to the MH department, ability of psychologists in PHC practices should also be which has full autonomy and responsibility in man- considered. aging funds, being the residual claimant. • The MH department disposes of community-based MH teams, with protocols with PHC practices, resi- Integrated community‑based care for SMI patients dential units, patients and families associations, reha- Rationale bilitation units, nursing homes, social services, and There is substantial evidence suggesting better out - local authorities. comes for SMI when treated in the community, while inpatient stays are associated with poorer health out- Also, the payment includes a P4P component: comes and risk of readmissions [34]. Despite this evi- dence, there are few community-based MH teams in • A bonus (penalty) for the hospitals in the lowest Portugal, while the current hospital financing model (highest) decile of the distribution in terms of inpa- is volume-based, favoring more frequent consultations tient stays. and inpatient stays. • A bonus (penalty) for the hospitals in the lowest (highest) decile of the distribution in terms of post- discharge consultations up to 30 days after discharge. Intervention • A budget penalty in case the hospital does not con- The model to be favored is that of community-based tribute and update a national registry of SMI, specifi - MH teams, which are expected to improve access to care cally created within this new payment model. because of their proximity to patients’ homes and lower stigma; to improve reinsertion because the community- Finally, we suggest an implementation phase of this based setting allows better contacts with social care, fam- new payment scheme, in order to smooth the adaptation, ilies, and employers; to improve follow-up, which leads to collect new data, and evaluate its impact. The implemen - better health outcomes and efficiency through reducing tation will be limited to three hospitals in year 1, six hos- inpatient stays and emergency visits. pitals in year 2, and nine hospitals in year 3. The selection of hospitals for this pilot phase should be made using a random sampling method, from the Payment model universe of Portuguese NHS hospitals with a mental We suggest the implementation of a per period payment, health department from the Lisbon, Coimbra, and Porto according to which the hospital receives an annual pay- regions, where most patients are treated. We suggest ment for each patient registered with SMI, covering all selecting three hospitals used as “treatment group”, and healthcare services. three others as “control group”. Then, the same process The rules for the payment attribution are the following: will be replicated for the three following in year 2, and for the three last in year 3. • Diagnosed with SMI according to the International In their first implementation year, we suggest a 25% Classification of Diseases, 9th Revision, Clinical higher bundled payment, in order to favor the necessary Modification (ICD-9-CM): 292 (drug-induced men - changes in structures and teams. During the first 3 years, tal disorders), 295 (schizophrenic psychosis), 296 data will be collected on resource use, pathologies, and (affective psychosis), 297 (delirium illnesses), or 298 functionality, in order to refine the payment value and (non-organic psychosis). their risk-adjustment for functionality. Afterwards, the Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 8 of 10 new payment model and its values will be designed, and the representativeness of the people we interviewed. the implementation will be extended to all the hospitals In particular, only five (out of 22) experts were from belonging to the Portuguese National Health Service the North region, and none were from the (low-popu- (NHS). lated) Portuguese hinterland. Also, other professionals could have been interviewed, such as community work- Discussion ers, school teachers, or researchers in MH issues. If, as This paper proposes an innovative payment model for the expected, the project creates interest in policy-makers for Portuguese public MH system. This system departs from its implementation in practice, we suggest diffusing the the hypothesis that failures of previous plans, which have proposal through formal channels, and opening a period been largely highlighted in recent national and interna- for public discussion. Second, there is a vast literature on tional evaluations [2, 7], are the result of the neglecting the effects of payment schemes on physicians’ practices, of implementation processes, especially in ensuring that which inspired our model, but the literature is scarce suggested guidelines are properly financed and moti - on the empirical testing of their impact, and even much vated. This is why in this project we focus on a payment scarcer in the field of mental health. This is why we also model, as a means to implement best practices in MH. suggest implementing the model progressively, in order Much has been written about the influence of pay - to measure its effects carefully, before expanding it to the ment models on healthcare providers’ practices [35, 36]. whole country. Finally, we must repeat that all payment Surprisingly, only few studies have addressed the impact schemes have their weaknesses, and even combining of reimbursement schemes in MH. This is why the pro - various models through blended formulas may not suc- posal was mainly based on theoretical and empirical ceed in mitigating them. In particular, we propose to use studies not specifically oriented toward MH, validated in some way the pay-for-performance in all dimensions, by MH experts. This resulted in the view that all pay - which might be associated with excessive focus on incen- ments have serious limitations, so that “payment innova- tivized indicators, crowding-out intrinsic motivation, or tions that blend elements of fee-for-service, capitation, cheating on performance reporting [38]. Although the and case rates can preserve the advantages and attenuate evidence is ambiguous for these adverse effects, they may the disadvantages of each” [37] (p. 150). In other terms, be considered in the implementation process, through it appears clearly that blended payments are the most limiting the weight of the pay-for-performance in the promising option, combining several advantages of vari- physician remuneration. ous payment schemes, in order to diminish their adverse effects. In the meantime, we selected the areas and types Budget impact and other implications of interventions that best correspond to the current As our proposal is largely centered around implementing weaknesses of the Portuguese MH system, and for which new financing mechanisms for MH providers, a major there was more evidence. issue is its sustainability, in a country marked by a rela- This proposal needs to be tested in practice, to confirm tively low GDP per capita compared to other European whether the expected benefits will materialize in practice, countries, and tight public health budgets. Some of our and not be compromised by unexpected adverse effects. suggestions are neutral from a budget viewpoint, as they It should be highlighted that preliminary meetings have merely redistribute money from low performers to high taken place at the Central Administration of the Health performers, in the case of pay-for-performance (dimen- System (ACSS), the Portuguese institution that defines sions 1, 2, and 3), or redistribute the money paid on the and implements the financing of NHS healthcare provid - basis of volume into per-patient payments (dimension ers, in order to implement pilot projects following our 4). However, in dimension 1 we propose a bundled pay- recommendations. This is a promising step because these ment to the PHC team for the follow-up of children at pilot projects include a close evaluation of their effective - risk or with special needs during the first 2 years of life; in ness and cost-effectiveness. Thus, we will be able, in the dimension 2, we suggest the payment of an additional fee following months, to produce outcomes that we expect to GPs for each follow-up consultation; and in dimension to be useful for Portugal and for other mental health sys- 3 the payment of a fixed monthly fee to compensate these tems facing similar difficulties. physicians for the extra work, respectively. Considering an estimated number of 4722 children at risk and prices Limitations of each type of consultations, the annual budget impact Our proposal suffers from some limitations that should of dimension 1 may vary between 1.3 and 2.4 million be mentioned. First, the proposal was presented to and euros. Considering 1,964,862 children in the ages for the validated by only a limited group of experts, selected by follow-up consultations, and a fee of 15 euros per consul- convenience. The choice of a convenience sample limited tation, the annual budget impact of dimension 2 would Perelman et al. Int J Ment Health Syst (2018) 12:25 Page 9 of 10 Nova School of Business and Economics, Universidade NOVA de Lisboa, be of 29.5 million euros. Finally, considering the 857 pri- Campus de Campolide, 1099-032 Lisbon, Portugal. mary care centers and 110 hospitals, and a monthly fee of 124 euros to GPs and specialists, the annual budget Acknowledgements We would like to thank all of the panel experts for their availability and impact of dimension 3 would be of 1.2 million euros. In valuable comments. We are particularly grateful to Dr. Álvaro de Carvalho, other terms, the budget impact of the proposal would be who encouraged and supported the idea of revising the current financing of 33.1 million euros per year, i.e., 0.36% of the total pub- model of the mental health system, and who embraced this project from the beginning. lic health expenditures (9130 million euros in 2017). Note, however, that providers’ payment mechanisms Competing interests are only one among other possible instruments to pro- The authors declare that they have no competing interests. mote best practices in MH, so that it should be accompa- Availability of data and materials nied by investments in community-based care facilities, Not applicable. continuous training and support for GPs, a greater auton- Consent for publication omy for primary care and mental health department Not applicable. managers, and the reinforcement of primary care teams with psychologists. These investments also require an Ethics approval and consent to participate Not applicable. increasing awareness on the part of the population and decision-makers about the burden of MH disease, which Funding financing models cannot achieve. This study was part of the investigation Project 00065SM1, funded by Norway, Iceland, and Liechtenstein, through the EEA grants, and inserted in the pro- gram “Public Health Initiatives”, of ACSS. Conclusion Publisher’s Note The Portuguese MH system suffers from various weak - Springer Nature remains neutral with regard to jurisdictional claims in pub- nesses, and has failed to implement WHO recommen- lished maps and institutional affiliations. dations on best practices. This failure is largely related Received: 29 September 2017 Accepted: 11 May 2018 to inadequate payment and incentives to providers. To overcome this problem, we designed an alternative pay- ment model for primary care and hospitals on the basis of the literature and experts’ consultation. The model References focuses on prevention and detection of diseases early in 1. World Health Organization. Improving health systems and services for mental health. 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International Journal of Mental Health SystemsSpringer Journals

Published: May 30, 2018

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