title: Incorporating shared savings programs into primary care: from theory to practice.
abstract: BACKGROUND
  In several countries, health care policies gear toward strengthening the position of primary care physicians. Primary care physicians are increasingly expected to take accountability for overall spending and quality. Yet traditional models of paying physicians do not provide adequate incentives for taking on this new role. Under a so-called shared savings program physicians are instead incentivized to take accountability for spending and quality, as the program lets them share in cost savings when quality targets are met. We provide a structured approach to designing a shared savings program for primary care, and apply this approach to the design of a shared savings program for a Dutch chain of primary care providers, which is currently being piloted.
  
  
  METHODS
  Based on the literature, we defined five building blocks of shared savings models that encompass the definition of the scope of the program, the calculation of health care expenditures, the construction of a savings benchmark, the assessment of savings and the rules and conditions under which savings are shared. We apply insights from a variety of literatures to assess the relative merits of alternative design choices within these building blocks. The shared savings program uses an econometric model of provider expenditures as an input to calculating a casemix-corrected benchmark.
  
  
  RESULTS
  The minimization of risk and uncertainty for both payer and provider is pertinent to the design of a shared savings program. In that respect, the primary care setting provides a number of unique opportunities for achieving cost and quality targets. Accountability can more readily be assumed due to the relatively long-lasting relationships between primary care physicians and patients. A stable population furthermore improves the confidence with which savings can be attributed to changes in population management. Challenges arise from the institutional context. The Dutch health care system has a fragmented structure and providers are typically small in size.
  
  
  CONCLUSIONS
  Shared savings programs fit the concept of enhanced primary care. Incorporating a shared savings program into existing payment models could therefore contribute to the financial sustainability of this organizational form.
authors.affiliation: Tilburg School of Social and Behavioral Sciences, dpt. Tranzo (Scientific center for care and welfare), Tilburg University, Address: PO Box 90153, 5000, Tilburg, LE, The Netherlands. a.p.hayen@tilburguniversity.edu.|National Institute for Public Health and the Environment, Centre for Nutrition, Prevention and Health Services, Address: PO Box, 3720, Bilthoven, BA, The Netherlands. a.p.hayen@tilburguniversity.edu.
authors.forename: Arthur P
authors.initials: AP
authors.lastname: Hayen
authors.affiliation: National Institute for Public Health and the Environment, Centre for Health and Society, Address: PO Box 1, 3720, Bilthoven, BA, The Netherlands. michael.van.den.berg@rivm.nl.
authors.forename: Michael J
authors.initials: MJ
authors.lastname: van den Berg
authors.affiliation: Tilburg School of Economics and Management, dpt. CentER (Center for Economic Research), Tilburg University, Address: PO Box 90153, 5000, Tilburg, LE, The Netherlands. b.r.meijboom@uvt.nl.
authors.forename: Bert R
authors.initials: BR
authors.lastname: Meijboom
authors.affiliation: National Institute for Public Health and the Environment, Centre for Nutrition, Prevention and Health Services, Address: PO Box, 3720, Bilthoven, BA, The Netherlands. jeroen.struijs@rivm.nl.
authors.forename: Jeroen N
authors.initials: JN
authors.lastname: Struijs
authors.affiliation: IQ Healthcare (Scientific Institute for Quality of Healthcare), Radboud University Medical Center, Address: PO Box 9101, 114, 6500, Nijmegen, HB, The Netherlands. gert.westert@radboudumc.nl.
authors.forename: Gert P
authors.initials: GP
authors.lastname: Westert
mesh_terms: D019985:Benchmarking / Q000191:economics; D017046:Cost Savings / Q000191:economics*; D003695:Delivery of Health Care / Q000191:economics; D018166:Health Care Reform / Q000191:economics; D005102:Health Expenditures; D006282:Health Personnel / Q000191:economics; D006291:Health Policy / Q000191:economics; D006801:Humans; D009426:Netherlands; D058007:Physicians, Primary Care / Q000191:economics; D010865:Pilot Projects; D011320:Primary Health Care / Q000191:economics* / Q000458:organization & administration; D011446:Prospective Studies; D018570:Risk Assessment