PHSSR Policy Roadmaps for Acting Early on NCDs Synthesis Report 2025

76 Acting early on NCDs The Partnership for Health System Sustainability and ResilienceManagement Programmes (DMPs) (see Chapter 5) and regional selective contracts under §140a SGB V (“besondere Versorgung”). Both are reimbursed extra-budgetarily, creating incentives for providers to deliver services not otherwise rewarded in the standard fee-for-service catalogue. Japan has incorporated lifestyle disease management fees and disease-specific treatment management fees into its medical reimbursement structure, explicitly recognising and valuing the coordination and comprehensive management required for effective chronic disease care (MHLW, 2024h). These supplementary payments provide modest incentives for prevention and coordination, though they remain small relative to procedure-based payments. The limited impact suggests the need for further improvements to promote prevention and outcome-based payments. Greece has employed quality-based rebate systems for some private providers, with rebate levels for diagnostic services, such as CT and MRI scans, tied to meeting specific quality standards, creating financial incentives for quality improvement. This approach recognises that penalising poor quality may be more effective than rewarding good performance, though international evidence on rebate effectiveness is mixed. Poland provides additional funding to primary healthcare clinics that participate in standardised preventive programmes and implementation of care coordination models, This approach links payment to process measures rather than outcomes, potentially easier to implement but with uncertain impact on patient health. The focus on process compliance may also increase administrative burden without necessarily improving care quality. The limits of payment reform Canada illustrates the difficulty of achieving meaningful change through small-scale financial incentives layered onto existing models. Primary care physicians are paid through a mix of fee-for- service and capitation, depending on the province, but neither approach has been designed to support comprehensive NCD management. Bonus schemes have been tried to fill this gap: Ontario offers payments for reaching cancer screening targets, and British Columbia introduced incentives for managing multiple chronic conditions. Yet evaluations show little impact, with Lavergne et al. (2018) finding “no observable effects” in BC. These experiences underline that bonus payments attached to volume-based models rarely overcome the underlying incentive misalignment (Lavergne et al., 2018). Poland has taken a different route by linking additional funding to participation in standardised preventive programmes and care coordination models. This approach of linking payment to process measures (such as participation in preventive programmes) may be more feasible to implement than outcome-based schemes, though evidence suggests limited impact on actual health outcomes. Most studies of outcome-based payment demonstrate minimal effectiveness, with substantial transaction costs and administrative burdens of designing and operating complex payment systems frequently overlooked in policy discussions. Providers resist income volatility associated with performance payment, particularly when factors beyond their control affect outcomes. Public expectations regarding provider choice and access create political barriers to payment models that might limit service availability. The persistence of traditional fee-for-service mechanisms across diverse health systems reflects not merely institutional inertia, but genuine structural challenges. Creating effective alternatives requires not just new payment models but supporting infrastructure including information systems to track performance, risk adjustment mechanisms to ensure fair comparison, and governance structures to manage complex contracts. These requirements may exceed the administrative capacity of many health systems, particularly those already struggling with basic service delivery. Rather than pursuing technocratic payment reforms in isolation, countries may achieve greater impact by prioritising fundamental changes to care delivery models. This includes fostering organisational integration across care settings, implementing multidisciplinary team-based