PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

75 Acting early on NCDs The Partnership for Health System Sustainability and Resilienceinsurance, create systematic disadvantages for rural populations that compound geographic access barriers (MHLW, 2023e). Elderly patients on fixed incomes face particular challenges, as travel costs represent larger proportions of limited budgets. Provider payment models and incentive alignment Fee-for-service payment systems continue to dominate across studied countries, creating powerful incentives that directly contradict the requirements of effective NCD prevention and management. These payment models reward volume over value, acute interventions over prevention, and fragmented care over coordination. The persistence of fee-for-service Germany’s fee-for-service system illustrates the perverse incentives created by volume-based payment. Providers are reimbursed for each discrete service but usually receive no compensation for time spent consulting with other providers or coordinating care across settings. This contributes to fragmented care and likely Germany’s persistently high rates of avoidable hospitalisations for chronic conditions such as diabetes, COPD, and heart failure (Blümel et al., 2022; Busse et al., 2024; OECD, 2023a). Average consultation times under eight minutes reflect how providers respond to payment incentives by maximising volume, limiting opportunity for prevention counselling or comprehensive chronic disease management. Canada’s experience mirrors these challenges, with fee-for-service payment remaining dominant in primary care. Some provinces have experimented with alternative models including capitation-based funding arrangements, though uptake remains limited. Others have attempted payment reforms through bonus schemes – Ontario provides payments for reaching cancer screening targets, while British Columbia introduced bonuses for managing multiple chronic conditions. However, evidence shows these had ’no observable effects on these outcomes’ (Lavergne et al., 2018), suggesting that bonus payments layered onto fee-for-service cannot overcome fundamental volume-based incentives. France’s fee-for-service model similarly encourages high service volumes over health outcomes, discouraging prevention activities and disease management interventions that are time consuming. Providers respond to low reimbursement rates by increasing volume to maintain income levels, creating a vicious cycle of supply-induced demand that drives up costs without improving outcomes. The France report finds that système du tiers payant, whilst reducing point-of-service barriers for patients, does not address underlying incentive misalignment that prioritises procedures over prevention. Spain’s payment systems vary by region but generally maintain fee-for-service for specialist care whilst using capitation or salaries for primary care. This creates incentive disparities between care levels, with specialists rewarded for activity whilst primary care providers managing most chronic disease receive fixed payments regardless of quality or outcomes (Bernal-Delgado et al., 2024). The misalignment contributes to the system’s hospital-centricity, as payment flows follow patients to specialist settings rather than supporting comprehensive primary care management. Innovations in payment reform Some countries have introduced innovative payment approaches that begin to align financial incentives with NCD management objectives, though implementation remains limited and evidence of effectiveness mixed. Germany’s experience shows how payment reform can reinforce structured chronic care. Two integrated-care approaches operate outside the capped outpatient budget: nationwide Disease