Table 1 Healthcare system performance objectives or domains considered to be relevant to assess care payment system effects

1. Clinical effectiveness and patient safety

The degree to which the level of health gain is maximized and harm to patients is minimized as a consequence of care. This domain refers to the effect of the payment scheme, and its sustainability, on patient outcome in a broad sense (life expectancy, relief of pain, functional capacity, etc.).

2. Best practice service use

The degree to which services are provided based on scientific knowledge to all who could benefit (avoiding underuse) and are refrained from being provided to those not likely to benefit (avoiding overuse). This implies that (1) patients do not receive care that cannot help them and/or the risks of which outweigh the benefits and (2) patients reliably receive care where the known benefits outweigh the risks.

3. Care equity

The degree to which care and its optimal outcome are delivered and attained for all people, without variation based on patient characteristics (such as gender, age, ethnicity, geographical location and socioeconomic status), unless there is a valid clinical rationale.

4. Care coordination, teamwork and continuity

The degree to which provider contributions are well integrated to optimize the delivery of care by the same healthcare provider throughout the course of care, with appropriate and timely communication, referral and collaboration between providers (both within and between provider organizations).

5. Patient centeredness

The degree to which care is respectful of and responsive to individual patient preferences and values, ensuring that patient preferences and values guide major clinical decisions.

6. Timeliness

The degree to which waits and delays are avoided.

7. Short term cost containment and budget safety

The degree to which expenditure of financial resources is contained in short term. Short term expenditure may not only be due to cost of care (including potential waste), but also due to investment in system organization (e.g. cost of implementation).

8. Long term cost containment and budget safety

The degree to which expenditure of financial resources is contained in long term. Long term expenditure may not only be due to cost of care (including potential waste), but also due to maintenance of system organization (e.g. cost of measuring and updating).

9. Provider wellness

The degree to which provider wellness is sustained, improves or deteriorates, as affected by job satisfaction, income (in)security, workload, autonomy and respect of professional values.

10. Innovation

The degree to which innovation of care, at the clinical treatment and/or organizational system level, is encouraged. This includes the strategy and investment focus of the provider (e.g. on quality vs. quantity).

11. Gaming the system

The degree to which providers consciously or unconsciously manipulate the system to increase personal financial gain. Gaming includes both data manipulation and/or patient selection (shifting care for high expenditure patients to other providers or providing less than appropriate care).