2013, Cilt 3, Sayı 2, Sayfa(lar) 128-132
Performance Based Supplementary Payment Systems in Istanbul Public Hospitals
Ayşegül YILDIRIM KAPTANOĞLU
Trakya University, Faculty of Health Sciences, Department of Health Management, Edirne, Turkey
Keywords: Healthcare transition in Turkey, Current supplementary payment, Public hospitals
Since 2003 new healthcare reforms have been implemented in Turkey. Although, the healthcare system has gone through modifications for
the past several years; there is insufficient research to demonstrate the effects of these changes. This paper aims to address the issues in the
supplementary payment systems, which are one of the recent changes of the healthcare system in the country. This study is mainly based
on a review of the relevant professional literature, a research and interpretation of supplementary payment in the public hospitals. This is a
research as well as an assessment work done in secondary and tertiary care hospitals. Performance based supplementary payment system
in public hospitals aims to provide bonuses to health care employees like physicians, nurses, etc. The bonus is given to professionals, who
produce the qualified health services based on records by the evaluation of the whole institution. Financing of supplementary payment
system in Turkey is mainly based on social security premiums. Consequently, balance of income and expenditures at hospitals is needed to
be followed sensitively. According to this study, physicians' productivity has increased but number of patients per physician has decreased.
Also, the amount of performance paid to the physician for their specialty has decreased. Physicians like cardiologists can benefit more
from the pay for performance system as their work contributions are paid more compared to internist work. Also secondary care hospital
staffs were better paid compared to tertiary care hospitals because more critical cases are sent to tertiary care and treatment of such cases
are of high cost. The reforms resulted satisfactory and very successful improvement in healthcare performance. The main health indicators
are now better than at the beginning of the transition period. The sustainability of the reform processes will cause further improvement
in the near future. The number of treatments per patient is increased not the number of patient and this may cause an escalated demand.
Some precaution such as to control referral of a patient to a tertiary care when the care is possible in the secondary care units is needed to
be taken. Complicated or critical patients mean great cost to hospital's revolving funds which means less money to the health staff via pay
for performance system in secondary and especially tertiary care.
The Turkish Health Care System has undergone several reforms
during health care transition period (2003-2012). Minister
of Health has pursued the cost control policies with radical
reforms of the overall management and organization of the
health care system since 2003-2004. Therefore, health care
professionals (principally physicians, nurses) tensions have
long been characterized the political economic evolution of
Turkish national health services (Yildirim Kaptanoglu, 2011).
Some Examples of Reforms: Family physician with family health
care centre practice application and the hospital union
belonging to Turkish Public Hospital Trust Union (PHTU) have
settled down by Ministry of Health (MoH). Turkish social health
insurance system (SGK) has undergone significant reforms. The
three insurance funds, namely SSK, Emekli Sandigi and Bag-
Kur, were merged under a sole body called the Social Security
Institution (SSI) in 2007. The three insurance funds together
cover around 81% of the population as of 2012 (http://www.
invest.gov.tr). The system started to be fully operational at the
beginning of 2008. Universal health insurance system was also
introduced (Yildirim Kaptanoglu, 2011). The Turkish healthcare
system is mostly financed by general taxes (41%), insurance
premiums (31%), and out-of-pocket payments (28%). If the
wage of a person is lower than the 1/3 of the minimum wage
that is currently 803,68TL-321.798 he/she could benefit from
resources of the SSI without paying premiums (http://www.
Use of Health Services in Turkey Currently: After 2011, the
mandatory Turkish Public Health Insurance Systems cover all
public hospital and ambulatory care. Health care expenditures,
as a share of gross domestic product (GDP) are 6,7% in our
country. But out of pocket payment is 5,4% of GDP (Yardım,
Cilingiroglu, & Yardim, 2013).
In 2000, roughly half of Turkish SSI expenditures were financed
by employer payroll taxes (67,2%) and a general social contribution
(36,5%) levied by the Turkish treasury on all earnings,
including investment income (http://www.kalite.saglik.gov.tr).
The health system in Turkey is dominated by family practice
centre for ambulatory care and public hospitals for acute
and chronic institutional care. All residents are automatically
enrolled with an insurance fund based on their occupational
status. In addition, 3-4% of the population subscribes to
supplementary private health insurance. Nowadays, another
supplementary private insurance has been adopted by government
to cover other benefits not covered under social security systems like an example of co-payment method (http://www.
Another distinguishing feature of the Turkish health system is
the attainability to all insured resident whether or not he or
she is ill. Family physician does not have gatekeepers regulating
access to refer specialists and hospitals (Yildirim Kaptanoglu,
2011). Primary care is dominated by family health care officebased
solo or group practices. Primary care physician deals
with program for maternal and child health cares mostly (MoH,
Hospital care is dominated mostly by public hospitals, including
research and teaching institutions with a monopoly on post
graduate medical education and research. There are, nevertheless,
opportunities for physicians in public hospital who wish
to have part-time private hospital staff. The private hospital
sector in Turkey (both non-profit and proprietary hospitals) has
14% of beds (Yenimahalleli Yasar, 2011). Proprietary hospitals,
typically smaller than public hospitals, have traditionally emphasized
elective surgery and obstetrics, leaving more complex
cases to the public sector. Over the past 5 years, some chain
private hospitals have developed a strong capacity for cardiac
surgery, chemotherapy, oncology, and transplantation therapy
(Yildirim Kaptanoglu, 2011).
Physicians in private practice and in proprietary hospitals are
paid directly out of pocket by patients. Following an overview
of the system and an assessment of its achievements,
problems and reform, this article point's current situation at
Performance based Supplementary Payment Systems (PBSP) in
Public Hospitals in Turkey.
PBSP system main objective is to encourage job motivation
and productivity among public hospital health staff especially
physicians in order to improve performance of the public hospitals
belonging to Ministry of Health (MoH, 2008; OECD-WB,
The PBSP system in Turkey can be categorized into less than
1. Before 2004: Performance-based contribution payment
system, which was first a pilot implementation at 10 hospitals
in 2003, has been implemented across all over Turkey
from 2004 on.
2. The supervisor of the staff makes performance evaluation
subjectively and it has no relation with the amount of output
produced by the staff. (Tengilimoglu, Pay, & Kisa, 2008).
3. PBSP after 2004: In order to make smooth transition to PBSP
system, it was aimed to motivate health care staff working
in hospital to provide high quality health care. (MoH, 2008).
4. 2004-2007: Quality Improvement and Performance Evaluation
System was developed until 2007.
5. After 2007 up till 2011: At public hospitals scores were
given to physicians providing the work that they had done
(outpatient or inpatient follow up, minor or major surgical
operation, medical intervention). In the public training and
research hospitals, teaching staffs were also given additional
scores to provide theoretical and practical training,
scientific publications and specialty training (MoH, 2008).
6. 2012 onwards: On performance management, national
standards and targets were introduced according to the
criteria of Clinical Excellence.
Current Situation: In public hospital Pay-for-performance (P4P)
programs are designed to offer financial incentives to physicians
and nurses to meet defined quality, efficiency. The Agency
for Healthcare Research and Quality mentions that this may
be defined as a strategy to improve health care delivery. P4P
systems in our country are trying to improve quality and patient
The aim of the study in this aspect is to measure hospital
performance in Istanbul, which may be a reflection of all over
Hospitals were grouped according to the number of their beds
and in every homogeneous group 10% of the total number
of secondary and tertiary care hospital was selected. So, six
secondary care hospitals and six of tertiary care public hospital
in Istanbul using a P4P system were randomly selected.
Index of Hospital Quality (IHQ) scale is used to collect data.
In the statistical analyses, the IHQ total score is used. IHQ is a
more exact and objective measure of performance in hospitals
settings (Vogeli, Hasnain-Wynia, Kang, Landrum, & Weissman,
2008). This scale describes hospital eligibility criteria and the
procedures used to measure P4P.
In these hospitals internal medicine speciality and surgical
speciality P4P mean the amount money when the physicians'
specialties were compared.
In the statistical analyses, the IHQ score is used; it is a more
exact and objective measure in performance scoring. P4P
mean amount delivered to oncologist, cardiologist, general
surgery and internal subspecialty separately were compared.
The average amount of the P4P in between oncologist, cardiologist,
general surgery and internal subspecialty in randomly
selected six tertiary care hospitals were compared. IHQ scores
follow a normal distribution.
Hypotheses are as follows:
H0: There is not a statistically significant relationship according
to P4P money amount by using IHQ scale between secondary
and tertiary hospitals.
H1: There is a statistically significant relationship according to
P4P money amount by using IHQ scale between secondary and
H0: There is not a statistically significant relationship between
average amount of the P4P money between oncologist, cardiologist,
general surgery and internal subspecialty compared to
tertiary care hospitals.
H1: There is a statistically significant relationship between
average amount of the P4P money between oncologist, cardiologist,
general surgery and internal subspecialty compared to
tertiary care hospitals.
The mean performance score of Index of Hospital Quality (IHQ)
for secondary care hospitals is 30.63 (SD = 11.31) and for tertiary
care hospitals is 26.42 (SD = 10.02). For the control variable
of hospital size -- represented by number of beds -- the mean
number of beds for secondary care is 452 (SD = 191) and for
tertiary care is 681 (SD=186).
The key result is that secondary care hospitals give better P4P.
The finding is presented in a graphical form in Figure 1.
Click Here to Zoom
|Figure 1: IHQ
mean score of
There is a statistically significant difference between IHQ score
of physician in secondary care compare to tertiary care according
to P4P money [t=15,62; p<0,001].
Relationship between average amount of the P4P money
between oncologist, cardiologist, general surgery and internal
subspecialty compared to tertiary care hospitals. P4P mean
money amount per month were compared with IHQ score of
oncologist, cardiologist, general surgery and internal subspecialty.
Physician like cardiologist mean P4P per month contributions
are compared with different subspecialty work and statistically
differences were found (F= 8.91; p<0.005).
The regression equations reveal that for tertiary care hospitals,
the R-squared is 0.12.
The regression equation is IHQ Score= 3.10 + 0.12 x Subspecialty.
A variable for the size of hospital, the number of beds, was
checked as one possible confounding factor. The mean number
of beds per hospital is 410 (SD = 95).
This article-reviewed change in the issues associated with P4P
in the Turkish health insurance system, and envisioned a picture
of effective P4P. Turkish health care P4P system has been made a principle that the Turkish Social Security System pays
the hospitals according to the diagnosis related group (DRG)
and Health Implementation Application (HIA called SUT in
Turkish literature). This payment method is under discussion
whether to pay the medical group or institution, or its individual
health care workers. Some authors have stressed the
enabling role at an institutional level to control the rewards to
individual workers. Rewards could be financial or non-financial
or a combination of both. The insurer can pay to the institution,
which in turn pays to individual workers according to its own
standards (Scott, Sivey, Ait Ouakrim, Willenberg, Naccarella,
Furler, & Young, 2011).
This study offers the evidence-based way of the current situation
of P4P system according to medical specialty in secondary
and tertiary cares hospitals. Based on these analyses, physicians
benefit more from P4P system in secondary care hospital
compare to tertiary care. Physicians are making much more
procedures in order to get money by P4P system. Because of
this situation hospital cost increase over time with the use of
more unnecessary care and drugs. Hospital and productivity
were slowing down, performance-related pay system as designed
by Turkish public hospitals. Physician like cardiologist (invasive
treatment) can benefit P4P system because their work
contributions are more paid compared to internal subspecialty
work (patient follow up). The study found that the Turkish
hospitals experience difficulties involving physicians in P4P
systems. This was partly because physicians of public hospitals,
which belong to MoH, did not want to lose their control over
hospital resource allocation. The low-level future orientation
dimension of hospital staff culture seems to cause weak future
orientation at hospitals. Up today, Turkish experiences show
the increase of public hospital autonomy. Government monitor
hospitals closely with strict regulations that limit opportunistic
behaviour of physician and hospital manager. In tertiary care
hospital physician productivity increased, number of patients per physician has increased by 30%. But, tertiary care hospitals
spend much more to their patients. SIS of Turkey pays money
according to diagnostic packages only. In this case, some of the
expenses like extra diagnostic procedures not covered in the
package are paid by revolving funds. But, it seems that current
situation of the P4P could result in an increase in health costs
by the provision of unnecessary care. At the end of undesirable
situation of P4P, a huge waste in social resources of Turkey will
take place (Aktaş, Yildirim Kaptanoğlu, Ozkan, Kaysın, & Silte,
Click Here to Zoom
|Figure 2: The average
amount of the
p4p of four
in tertiary care
Performance indicators need to be monitored on a continuous
basis. It is important to allocate sufficient time and resources
to ongoing management of the program (Werner 2008). Most
importantly, high-quality quality indicators for clinical care
should be mapped out by combining claims information and
information available in registries (Damberg, Sorbero, Mehrotra,
Teleki, Lovejoy, & Bradley; 2009). When such a basis has
been provided to some degree, national health system performance
reports should be published periodically by combining
such quality indicators and data on inputs of the health system
as well as medical expenditures. This in turn will function as a
strong catalyst for the progress (Nahra, Reiter, Hirth, Shermer,
& Wheeler 2006).
P4P system could only improve hospital financial sustainability
if hospital bonus distribution should be based on doctor performance
measured by health indicators that are in line with
the desired overall performance of the health care system in
the country (Xingzhu, & Mills, 2005).
Future research is needed to expand the findings of this study
that sidestep results based management practices.
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