Getting financial incentives right for improving care coordination: lessons from France

Purpose: The paper aims to assess the incentives of common payment mechanisms for improving care coordination, using French experience. Context: Chronic diseases account for most of the disease burden in Europe. Ensuring appropriate and efficient care for people with chronic conditions has become an issue of increasing importance in many countries. In order to achieve better care coordination, integration and quality of health care, new payment mechanisms are required covering the full range of health professionals involved. This is challenging as most health systems are organised as clusters of services and providers. State of the art: In France health care provision relies heavily on self-employed health professionals paid on a fee-for-service basis. In hospitals, activity-based payment has been introduced recently with the objectives of improving quality and efficiency of care. But, the division between primary and secondary care gives little incentives to providers for coordinating care across settings. We present recent payment reforms for secondary and primary care in France and provide evidence for their effects on quality and costs. We also analyse the incentives of these payment mechanisms for care coordination. The situation of France is then put into the context of payment reforms in other countries in order to draw general lessons about payment systems and options for improving current models. Statements for debate: Payment methods and financial incentives play a key role in determining provider behaviour/ performance in integrated care delivery. In order to improve care provision for chronically ill and/or complex patients, payments should incentivise a long-term perspective centred on patient engagement, care coordination and side effect prevention. The traditional fee-for-service payment system which rewards service volume rather than improvements in outcomes and care quality is a barrier to improve care integration. Activity based payment in hospitals foster the development of hospital activity and, in its basic form, does not encourage care coordination nor improving care pathways. In order to encourage new delivery models, it is necessary to align the payment incentives of different providers.