Optimizing chronic healthcare payment scheme: integrating patient effort in service pricing for enhanced self-management performance

Abstract

PurposeThe study aims to address a critical gap in existing healthcare payment schemes and care service pricing by recognizing the influential role of patients' decisions on self-management efforts. These decisions not only impact health outcomes but also shape the demand for care, subsequently influencing care costs. Despite the significance of this interplay, current payment schemes often overlook these dynamics. The research focuses on investigating the implications of a novel behavior-based payment scheme, designed to align incentives and establish a direct connection between patients' decisions and care costs. The primary objective is to comprehensively understand whether and how this innovative payment scheme structure influences key stakeholders, including patients, care providers, insurers and overall social welfare.Design/methodology/approachIn this paper, we propose a game-theoretical model to incorporate the performance of self-management with the demand for healthcare service, compare the patient's effort decision for self-management and provider's price decision for healthcare service under a behavior-based scheme with that under two implemented widely payment schemes, that is, co-payment scheme and co-insurance scheme.FindingsOur findings confirm that the behavior-based scheme incentives patient self-management more than current schemes while reducing their possibility of seeking healthcare service, which indirectly induces the provider to lower the price of the service. The stakeholders' utility under various payment schemes is sensitive to the cost of treatment and the perceived health utility of patients. Especially, patient health awareness is not always benefited provider profit, as it motivates patient self-management while diminishing the demand for care.Originality/valueWe provide a novel framework for characterizing behavior-based payment schemes. Our results confirm the need for modification of the current payment scheme to incentivize patient self-management.