Attribute development and level selection for a discrete choice experiment to elicit the preferences of health care providers for capitation payment mechanism in Kenya

Background Stated preference elicitation methods such as discrete choice experiments (DCEs) are now widely used in the health domain. However, the “quality” of health-related DCEs has come under criticism due to the lack of rigour in conducting and reporting some aspects of the design process such as attribute and level development. Superficially selecting attributes and levels and vaguely reporting the process might result in misspecification of attributes which may, in turn, bias the study and misinform policy. To address these concerns, we meticulously conducted and report our systematic attribute development and level selection process for a DCE to elicit the preferences of health care providers for the attributes of a capitation payment mechanism in Kenya. Methodology We used a four-stage process proposed by Helter and Boehler to conduct and report the attribute development and level selection process. The process entailed raw data collection, data reduction, removing inappropriate attributes, and wording of attributes. Raw data was collected through a literature review and a qualitative study. Data was reduced to a long list of attributes which were then screened for appropriateness by a panel of experts. The resulting attributes and levels were worded and pretested in a pilot study. Revisions were made and a final list of attributes and levels decided. Results The literature review unearthed seven attributes of provider payment mechanisms while the qualitative study uncovered 10 capitation attributes. Then, inappropriate attributes were removed using criteria such as salience, correlation, plausibility, and capability of being traded. The resulting five attributes were worded appropriately and pretested in a pilot study with 31 respondents. The pilot study results were used to make revisions. Finally, four attributes were established for the DCE, namely, payment schedule, timeliness of payments, capitation rate per individual per year, and services to be paid by the capitation rate. Conclusion By rigorously conducting and reporting the process of attribute development and level selection of our DCE,we improved transparency and helped researchers judge the quality.

Capitation is a payment method where health facilities are paid a fixed amount of money by health insurers (e.g. NHIF) for every member registered to that facility to provide services over a fixed period. The funds are paid in advance (i.e. before health care services are offered).
Capitation is based on numbers and risk pooling. It is based on numbers because the total amount of money a health facility is paid depends on the number of health insurance beneficiaries registered to that facility. If a facility has 1000 registered health insurance beneficiaries, and the insurer pays a rate of KES 1200 per member per year, then the facility expects to receive (1200 X 1000) KES 1,200,000 per year. Therefore, a facility with more registered health insurance beneficiaries would receive a higher amount as compared to one that has fewer members. For example, a facility with 1500 members will get (1200 X 1500) KES 1,800,000 while a facility with 500 members will receive KES 600,000 per year.
In addition, capitation has an aspect of risk pooling in that not all the registered health insurance beneficiaries will seek care at the same time. As a result, the costs of care of those who visit the facility are covered from the total capitation amount paid by the health insurer (e.g. KES 1,200,000 for the 1000 registered members) and not the rate per individual (e.g. 1,200). For example, if 300 out of the 1,000 registered members seek care at the facility over a one-year period, and each spends a total of KES 2,500, then the total costs incurred by the facility are (KES 2,500 X 300) KES 750,000. This means that the facility still makes a profit of (1,200,000 -750,000) KES 450,000.

Section C. Choice experiment (For the respondent to read)
Imagine you are to sign a contract with a health insurer (e.g. NHIF) to provide services to its members. You are to be paid using the capitation model. You will be presented with eight sets of tasks, each representing two alternatives of a possible capitation model of payment and a no choice alternative. These alternatives differ only by the levels of the following characteristics: 1. Payment Schedule -frequency of capitation disbursements which takes the form of either 1 month (Monthly), 3 months (Quarterly), 6 months (Bi annually -Twice a year), or 12 Months (Annually -Once a year)

2.
Timeliness of payments -Whether the capitation disbursements are made on time (by the agreed date) or not.

3.
Capitation rate per individual per year. This is the amount of money paid by a health insurer for an individual to cover the costs of services provided by the health facility to that person. This takes the form of KES 1200, 2400, 3600, and 4800 per individual per year.

4.
Services to be paid by the capitation rate. This refers to the number and type of services that the insurer pays for by capitation. For example, the insurer might pay for consultation, drugs, and lab tests by capitation, OR pay for consultation and drugs only by capitation, and pay for lab tests separately using another method such as fee for service.

5.
Performance requirements. Performance requirements might come attached to capitation payments. For example, a health facility might receive a base capitation rate only, or get the base capitation rate plus an additional bonus when they improve the quality of services that they offer to patients.
For each task, you will be asked to rank your preferred choice with (1) representing your best choice, (2) second best, and (3) your worst. Then, for the alternatives that you ranked (2) and (3), you will be prompted to indicated which one you find unacceptable (i.e. you would never choose that alternative?). Tick the remaining alternative as acceptable.

Practice choice tasks
Practice scenario 1 (Researcher to use this as a demonstration)

Performance requirements
Hospital receives base/fixed capitation rate Hospital receives base/fixed capitation rate + bonus for improved performance (e.g improved quality).
Please rank your preferred choice Best(1) to Worst (3) Among the alternatives that you ranked (2) and (3) which one is unacceptable to you (i.e. you would never choose that alternative?)

Performance requirements
Hospital receives base/fixed capitation rate Hospital receives base/fixed capitation rate + bonus for improved performance (e.g. improved quality).
Please rank your preferred choice Best(1) to Worst (3) Among the alternatives that you ranked (2) and (3) which one is unacceptable to you (i.e. you would never choose that alternative?)