Table 1 Types of value-based reimbursement models and their potential advantages and disadvantages in high-performance sport settings
Type of model | Description | Potential advantages | Potential disadvantages |
|---|---|---|---|
Fee-for-service | Providers are reimbursed separately for each distinct service provided | Simple to administer and enforce Ability to choose provider(s) No or limited management required of staff to the sporting organisation No on-costs of employment to the sporting organisation (e.g. leave loading, superannuation, long-service leave) Higher organisation control on what services are funded | May encourage over-servicing Can lead to fragmented/siloed care No or limited time allowed for coordination of care No incentives for prevention Providers may function independently rather than as a team Limited ability to design and implement prevention programmes Less autonomy in intervention choice for the provider |
Pay-for-performance | Providers are financially rewarded for reaching key quality or performance benchmarks | Explicitly incentivises positive athlete outcomes Demonstrates commitment to evidence-based healthcare Transparent rewards process Can be used to focus attention on high-risk individuals/groups May provide a mechanism for healthcare to be aligned to organisational goals | No incentives to reduce unnecessary or low-value services or contain costs Can disincentive providers from seeing athletes with needs outside of targeted benchmarks Complex to establish and agree on evidence-based quality measures Can be difficult to measure outcomes in complex cases |
Bundled payments | Providers receive a fixed, lump sum payment for a discrete episode of care for a given patient. Performance incentives are also commonly included in these models | Providers are discouraged from performing unnecessary or low-value interventions Strong incentive to avoid health-related complications Provider has flexibility to determine which services are offered to achieve the desired outcome | Can be difficult in sporting context to define what a discrete episodes of care would look like May encourage unnecessary episodes of care |
Shared savings/risks | Providers earn bonuses and/or penalties based on spending below a predetermined benchmark over a period (typically contingent on meeting quality targets) | Providers are discouraged from performing unnecessary or low-value procedures Benchmarks can be determined and aligned to organisation strategy Incentivises activity towards health long-term health/performance outcomes if identified in benchmarks (e.g. low recurrence rates of injuries) | Up-front costs associated with developing the health IT and quality measurement infrastructure needed to reduce healthcare costs Assumes that providers are overspending and could penalise those already performing well May encourage ‘cherry-picking’ and other gaming behaviours May not be sustainable after initial savings have been realised May not account for the fluctuation in injury rates within sports each season due to external events (rule changes, weather etc.) |
Organisational salary or contract-based provider engagement models | Providers are reimbursed based on agreed organisational priorities, regardless of the volume and type of services provided | Health services can be aligned with organisational priorities No incentives to provide low-value care Practitioners have one ‘boss’, reduced conflict between the sporting organisations goals and the healthcare providers/company goals Set salary/wage rather than market consultation fees | Need to manage staff performance Staff usually paid in salary, which may lead to complacency Staff on-costs need to be considered, e.g. superannuation, leave entitlements, backfill No incentive for performance typically Balance required for generalist vs specialist staff (with specialists typically being outside the in-house service) |
Capitation | Providers are reimbursed on a per-person plan, regardless of the volume of services provided | Incentivises providers to keep athletes as healthy as possible through preventive care Incentive to keep costs per athlete low Encourages greater coverage by incentivising providers to take on more athletes | Providers are at increased financial risk which may not be practical to manage Can be complex to establish and enforce May lead to low care quality, particularly through under provision of care May encourage providers to select the healthiest/least complex athletes |