Evaluation of financial incentives as a quality improvement strategy in the public hospital context : clinician attitudes, design variables, and economic costs

In 2008, a three-year pilot ‘pay for performance’ (P4P) program, known as ‘Clinical Practice Improvement Payment’ (CPIP) was introduced into Queensland Health (QHealth). QHealth is a large public health sector provider of acute, community, and public health services in Queensland, Australia. The organisation has recently embarked on a significant reform agenda including a review of existing funding arrangements (Duckett et al., 2008). Partly in response to this reform agenda, a casemix funding model has been implemented to reconnect health care funding with outcomes. CPIP was conceptualised as a performance-based scheme that rewarded quality with financial incentives. This is the first time such a scheme has been implemented into the public health sector in Australia with a focus on rewarding quality, and it is unique in that it has a large state-wide focus and includes 15 Districts. CPIP initially targeted five acute and community clinical areas including Mental Health, Discharge Medication, Emergency Department, Chronic Obstructive Pulmonary Disease, and Stroke. The CPIP scheme was designed around key concepts including the identification of clinical indicators that met the set criteria of: high disease burden, a well defined single diagnostic group or intervention, significant variations in clinical outcomes and/or practices, a good evidence, and clinician control and support (Ward, Daniels, Walker & Duckett, 2007). This evaluative research targeted Phase One of implementation of the CPIP scheme from January 2008 to March 2009. A formative evaluation utilising a mixed methodology and complementarity analysis was undertaken. The research involved three research questions and aimed to determine the knowledge, understanding, and attitudes of clinicians; identify improvements to the design, administration, and monitoring of CPIP; and determine the financial and economic costs of the scheme. Three key studies were undertaken to ascertain responses to the key research questions. Firstly, a survey of clinicians was undertaken to examine levels of knowledge and understanding and their attitudes to the scheme. Secondly, the study sought to apply Statistical Process Control (SPC) to the process indicators to assess if this enhanced the scheme and a third study examined a simple economic cost analysis. The CPIP Survey of clinicians elicited 192 clinician respondents. Over 70% of these respondents were supportive of the continuation of the CPIP scheme. This finding was also supported by the results of a quantitative altitude survey that identified positive attitudes in 6 of the 7 domains-including impact, awareness and understanding and clinical relevance, all being scored positive across the combined respondent group. SPC as a trending tool may play an important role in the early identification of indicator weakness for the CPIP scheme. This evaluative research study supports a previously identified need in the literature for a phased introduction of Pay for Performance (P4P) type programs. It further highlights the value of undertaking a formal risk assessment of clinician, management, and systemic levels of literacy and competency with measurement and monitoring of quality prior to a phased implementation. This phasing can then be guided by a P4P Design Variable Matrix which provides a selection of program design options such as indicator target and payment mechanisms. It became evident that a clear process is required to standardise how clinical indicators evolve over time and direct movement towards more rigorous ‘pay for performance’ targets and the development of an optimal funding model. Use of this matrix will enable the scheme to mature and build the literacy and competency of clinicians and the organisation as implementation progresses. Furthermore, the research identified that CPIP created a spotlight on clinical indicators and incentive payments of over five million from a potential ten million was secured across the five clinical areas in the first 15 months of the scheme. This indicates that quality was rewarded in the new QHealth funding model, and despite issues being identified with the payment mechanism, funding was distributed. The economic model used identified a relative low cost of reporting (under $8,000) as opposed to funds secured of over $300,000 for mental health as an example. Movement to a full cost effectiveness study of CPIP is supported. Overall the introduction of the CPIP scheme into QHealth has been a positive and effective strategy for engaging clinicians in quality and has been the catalyst for the identification and monitoring of valuable clinical process indicators. This research has highlighted that clinicians are supportive of the scheme in general; however, there are some significant risks that include the functioning of the CPIP payment mechanism. Given clinician support for the use of a pay–for-performance methodology in QHealth, the CPIP scheme has the potential to be a powerful addition to a multi-faceted suite of quality improvement initiatives within QHealth.

Soil carbon sequestration rates and associated economic costs for farming systems of south-eastern Australia

Soil organic carbon (C) sequestration rates based on the Intergovernmental Panel for Climate Change (IPCC) methodology were combined with local economic data to simulate the economic potential for C sequestration in response to conservation tillage in the six agro-ecological zones within the Southern Region of the Australian grains industry. The net C sequestration rate over 20 years for the Southern Region (which includes discounting for associated greenhouse gases) is estimated to be 3.6 or 6.3 Mg C/ha after converting to either minimum or no-tillage practices, respectively, with no-till practices estimated to return 75% more carbon on average than minimum tillage. The highest net gains in C per ha are realised when converting from conventional to no-tillage practices in the high-activity clay soils of the High Rainfall and Wimmera agro-ecological zones. On the basis of total area available for change, the Slopes agro-ecological zone offers the highest net returns, potentially sequestering an additional 7.1 Mt C under no-tillage scenario over 20 years. The economic analysis was summarised as C supply curves for each of the 6 zones expressing the total additional C accumulated over 20 years for a price per t C sequestered ranging from zero to AU$200. For a price of $50/Mg C, a total of 427 000 Mg C would be sequestered over 20 years across the Southern Region, <5% of the simulated C sequestration potential of 9.1 Mt for the region. The Wimmera and Mid-North offer the largest gains in C under minimum tillage over 20 years of all zones for all C prices. For the no-tillage scenario, for a price of $50/Mg C, 1.74 Mt C would be sequestered over 20 years across the Southern Region, <10% of the simulated C sequestration potential of 18.6 Mt for the region over 20 years. The Slopes agro-ecological zone offers the best return in C over 20 years under no-tillage for all C prices. The Mallee offers the least return for both minimum and no-tillage scenarios. At a price of $200/Mg C, the transition from conventional tillage to minimum or no-tillage practices will only realise 19% and 33%, respectively, of the total biogeochemical sequestration potential of crop and pasture systems of the Southern Region over a 20-year period.

Women's labor force participation and marriage : the case of Korea

In this paper, we examine the relationship between marital status and female labor force participation in Korea, and argue that marriage remains a major obstacle to young Korean women's employment. We find that an average married woman is much less likely (by 40–60%) to participate in the labor force than a single woman in urban Korea. Further investigation into the participation patterns among married women reveals that labor force participation rate (LFPR) varies with husband's occupation and her own age. Lower LFPR among the young married women is explained by demand-side factors, while relatively higher LFPR among the middle-aged married women is mostly explained by the supply-side factors.

Understanding business process models : the costs and benefits of structuredness

Previous research has put forward a number of properties of business process models that have an impact on their understandability. Two such properties are compactness and(block-)structuredness. What has not been sufficiently appreciated at this point is that these desirable properties may be at odds with one another. This paper presents the results of a two-pronged study aimed at exploring the trade-off between compactness and structuredness of process models. The first prong of the study is a comparative analysis of the complexity of a set of unstructured process models from industrial practice and of their corresponding structured versions. The second prong is an experiment wherein a cohort of students was exposed to semantically equivalent unstructured and structured process models. The key finding is that structuredness is not an absolute desideratum vis-a-vis for process model understandability. Instead, subtle trade-offs between structuredness and other model properties are at play.

The impact of infrastructure charges on new housing costs : an international comparison

Sourcing funding for the provision of new urban infrastructure has been a policy dilemma for governments around the world for decades. This is particularly relevant in high growth areas where new services are required to support swelling populations. Existing communities resist the introduction of new taxes to fund such infrastructure, hence the introduction of charges to the developer has flourished. The Australian infrastructure funding policy dilemmas are reflective of similar matters to some extent in the United Kingdom, and to a greater extent the United States of America. In these countries, infrastructure cost recovery policies have been in place since the 1940’s and 1970’s respectively. There is an extensive body of theoretical and empirical literature that discusses the passing on (to home buyers) or passing back (to the englobo land seller) of these increased infrastructure charges, and the corresponding impact on housing cost and supply. The purpose of this research is to examine the international evidence that suggests infrastructure charges contribute to increased house prices as well as reduced land supply. The paper concludes that whilst the theoretical work is largely consistent, the empirical research to date is inconclusive and further research is required into these impacts in Australia.

Land buyers likely to foot reform costs

Article in Courier Mail. Friday July 22, 2011.

Legal Profession Act 2007 s 319 - Whether costs agreement made after trial valid and enforceable - whether agreement had retrospective operation

The decision in QCOAL Pty Ltd v Cliffs Australia Coal Pty Ltd [2010] QSC 479 involved an examination of a number of issues relating to the assessment of costs under the Legal Profession Act 2007 (Qld). The decision highlights a range of issues which, in slightly different circumstances, may have deprived the successful party of the right to recover costs by reference to the costs agreement.

Interim bills and costs assessment : was the application in or out of time?

This article examines the decision in Turner v Mitchells Solicitors [2011] QDC 61 and the issue whether an application for assessment of costs under an interim bill at the time of a final bill is subject to the usual 12-month restriction.

The GST Compliance Costs Of Nonprofit Organisations

On 2 December 1998, the Federal Government tabled their policy paper entitled Regulation Impact Statement for the Introduction of a Goods and Services Tax (RIS) in the House of Representatives. The Federal Government predicted that total gross GST compliance costs to Australian businesses in the first year of implementation would be approximately $1,912 million (or $1,195 per firm). Furthermore, it is estimated that the recurrent net compliance costs will be much lower at $131 per firm. Whilst the government made brief references to charitable organisations in their analysis, it stated that the compliance costs faced by nonprofits would, in substance, be no different to the compliance costs faced by businesses or government departments. This paper examines the RIS process in relation to nonprofit organisations in the context of recent taxation legislation affecting nonprofit organisations. It argues that the assumption that nonprofit compliance costs are similar to government and business costs is flawed and makes a case for the RIS process to be reformed to include more appropriate assessments of the impact of legislation on nonprofit enterprises.

An estimate of road accident costs in Singapore

An earlier study by the Asian Development Bank (ADB) showed that the annual cost of road traffic accidents in 2001 was S$699.36 million which was 0.5% of the annual GDP. This paper attempts to update of the cost estimates of road traffic accidents. More precise methods of computing the human cost, lost output and property damage are adopted which grew in an annual cost of S$610.3 million or 0.338% of the annual GDP in 2003. A more conservative estimate of S$878,000 for fatal accident is also obtained, compared to the earlier figure of S$1.4 million. This study has shown that it is necessary to update the annual traffic accident costs regularly, as the figures vary with the number of accidents which change with time.

Soil carbon sequestration and associated economic costs for farming systems of the Indo-Gangetic Plain : a meta-analysis

Soil organic carbon sequestration rates over 20 years based on the Intergovernmental Panel for Climate Change (IPCC) methodology were combined with local economic data to determine the potential for soil C sequestration in wheat-based production systems on the Indo-Gangetic Plain (IGP). The C sequestration potential of rice–wheat systems of India on conversion to no-tillage is estimated to be 44.1 Mt C over 20 years. Implementing no-tillage practices in maize–wheat and cotton–wheat production systems would yield an additional 6.6 Mt C. This offset is equivalent to 9.6% of India's annual greenhouse gas emissions (519 Mt C) from all sectors (excluding land use change and forestry), or less than one percent per annum. The economic analysis was summarized as carbon supply curves expressing the total additional C accumulated over 20 year for a price per tonne of carbon sequestered ranging from zero to USD 200. At a carbon price of USD 25 Mg C−1, 3 Mt C (7% of the soil C sequestration potential) could be sequestered over 20 years through the implementation of no-till cropping practices in rice–wheat systems of the Indian States of the IGP, increasing to 7.3 Mt C (17% of the soil C sequestration potential) at USD 50 Mg C−1. Maximum levels of sequestration could be attained with carbon prices approaching USD 200 Mg C−1 for the States of Bihar and Punjab. At this carbon price, a total of 34.7 Mt C (79% of the estimated C sequestration potential) could be sequestered over 20 years across the rice–wheat region of India, with Uttar Pradesh contributing 13.9 Mt C.

Accounting for costs

In Golder Associates Pty Ltd v Challen [2012] QDC 11 Samios DCJ recognised a solicitor’s lien over the file for unpaid fees and confirmed that a lien should not be lightly set aside. The decision, which is under appeal, adds to the range of authorities which are now grappling with some of the provisions of the Legal Profession Act 2007 (Qld) (the LPA) relating to costs billing and assessment. These would appear to have been drafted without a great deal of intellectual rigour (cf. Turner v Mitchells Solicitors [2011] QDC 61 at [26]).

Pro Bono - But what about costs?

The decision of the Queensland Court of Appeal in King v King demonstrates that in proceedings in Queensland Courts legal practitioners acting pro bono should still consider at the outset whether it is desired to provide for recovery of costs which might be recovered from another party.