Pay for Quality

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86 Pay for Quality KCE Reports 118 There are some important points to consider when interpreting the results. These have to do with the purpose of P4Q (i.e. the basic philosophy supporting the concept), how to use it as a quality supportive tool and the expectations in terms of effect size. It seems that there are two ways of looking at P4Q. One philosophy sees P4Q as a broad target based rule set, mainly focusing on minimally required quality standards which are the same for all providers, and which remain relatively stable in terms of target selection. The target selection in this philosophy is mainly driven by the level of evidence supporting the target, being able to measure the target and providers having sufficient control over the targets. In this philosophy no adaptations are made according to local needs. National or regional needs guide the process. From this point of view, are the results above adequate to support widespread P4Q dissemination? The answer will be no if one expects P4Q to cause a ‘leapfrog’ jump in quality improvement on the whole set of targets, while keeping the programme fixed and static as it is. However, because in this philosophy local needs are not accounted for in terms of the potential room for improvement for specific targets, is such a ‘leapfrog’ expectation in fact not unrealistic? In many of the programmes on a number of the included targets an already pre existing high baseline level of target achievement was reached before P4Q programme implementation. For example one Australian study showed already a 100% performance on its most important target included. One cannot do better than 100% and for many targets it can be questioned how much improvement is still possible once thresholds of above 80 and 90% have been reached. If these targets are to be included in P4Q programmes, as a kind of long term control measure, then their result of showing no significant effect or a modest sized effect is likely the best that can be expected. This sheds already a completely different light over the wide range of results reported above. The above philosophy will lead to more and more of such no significant and small sized P4Q effects, as everybody will reach the thresholds during multiple feedback cycles. Then afterwards the programme may be refocused at other national or regional priorities. The results indicate that P4Q can fit such a purpose, however without getting the maximal P4Q effects possible out of the system. In the long run this leads to providers receiving a bonus for things they are already doing without changing behaviour. One can question whether this is the best option for society, both in terms of health gain as in terms of cost effectiveness as will be discussed in section 5.2.2 (page 87). There is however a second P4Q philosophy conceivable to amend the shortcomings mentioned above. As the results show, high effects can also be reached by implementing P4Q, but different ones according to local programmes and targets. This corresponds to the fact that the highest gains are found for providers performing the least on a specific target, as shown in several studies. So the purpose of a P4Q programme, instead of or combined with reaching top performance on all minimal measures, may also be to correct locally existing quality gaps. And the results indicate that P4Q may also fit this purpose when aligned with the targets with the highest local room for improvement. It is remarkable to note that almost no study really focused on local target relevance and timeliness as additional selection criteria. With relevance we mean that local baseline data are used to further prioritize final target selection, based on the identification of quality of care gaps. Timeliness points to the fact that P4Q can be used in a much more dynamical way than currently used by seeing it as part of the basic concept of quality improvement management: cycles of continuous improvement, also referred to as PDCA (plan do check act) cycles. These two criteria, which are fundamental to quality of healthcare theories and practice, are underused in current P4Q practice, as presented in evaluation studies. By simply making it possible for local providers and organizations to prioritize targets based on their biggest quality gaps a P4Q programme would become focused on those targets where the highest quality gains can be expected and the chance to reach high gains as compared to absent or small gains will increase. This modification will also raise local responsibility, involvement and awareness, which is sometimes lacking in current P4Q programmes. Finally, by such prioritizing the whole P4Q system automatically becomes much more dynamical, beyond a periodic review of target selection, towards a more continuous process.
KCE Reports 118 Pay for Quality 87 The current evaluation studies have shown that P4Q is a feasible concept to implement and that it shows the potential to fulfil its purpose, being a stable minimal standard approach and/or a more dynamical and focused approach. In the end we hypothesize that both options would reinforce each other, giving P4Q both a national/regional and local dimension. Next to clinical effectiveness there is also a quickly growing body of evidence on the equity of care effects, which will be extensively discussed in section 5.2.3. There is a lack of evidence of the effect of P4Q on other domains such as care continuity, care coordination, patient/provider experience and efficiency. Isolated studies show that directing P4Q at coordination of care also can result in substantial positive effects (58% on patient acceptance in emergency care, 23% on the referral rate for poor glycaemia control). However, as shown in emergency care, for P4Q to be effective on coordination, a one sided incentive system is unfit, and the incentives of the coordinating parties should be aligned. One Spanish study found absent or only positive effects of P4Q on patient and provider experience. The only negative aspect was a higher workload as perceived by physicians. It is clear that a lot more empirical research is necessary to clarify these effects. Another remarkable finding is the lack of attention for P4Q effects on the inappropriate use of resources. Although an acute sinusitis study found substantial decreases in the use of inappropriate drugs, medical imaging, etc. most P4Q programmes neglect such effects to avoid a connotation with a hidden cost containment goal as the primary P4Q purpose. However, correcting underuse in the use of drugs, testing and medical examinations will often coincide with a reduction of the previously used inappropriately used alternatives (e.g. one type of antibiotics instead of the other). These evolutions merit further investigation. In terms of unintended consequences the current results are consistent. Firstly, there seems to be no effect of P4Q implementation on other not incentivized quality targets. This means that there is neither a negative effect, nor a positive spill over effect. Some authors criticize the fact that there is often no direct relationship with patient outcomes such as readmissions, complication rate and mortality rate. Because P4Q is a new phenomenon it can however be questioned whether such a long term relationship can develop in such a short time frame. Measuring P4Q effects and long term outcome effects at the same time, right after P4Q implementation does not take into account that potential P4Q effects on those measures will take possibly years to develop, e.g. in the prevention of diabetes complications. Therefore, at present no sound conclusions concerning those effects may be formulated yet. 5.2.2 Reported cost effectiveness and modelling effects of P4Q programmes As stated by the three studies concerning cost-effectiveness, P4Q programmes can be cost-effective. From the 12 QOF indicators considered by Mason et al. (2008) 224 11 indicators seem to be cost-effective. Only one indicator, namely diabetes retinal screening was not cost-effective according to their economic framework. The USA hospital incentive programme for heart-related care, studied by Nahra et al. (2006) 107 , also seems to be cost-effective, both in worst as in best case scenario. And finally the study by Curtin et al. (2006) 107 , 225 concerning a pay for quality programme focussing on diabetes patients in primary care, shows a positive return on investment. It must be noted that these studies are mostly based on a few assumptions in cost and health gain, generally based on literature data. Consequently the results of these studies are estimates, and have to be treated with caution. In order for an indicator or a programme to be cost-effective, an absolute change between baseline utilisation and the end-utilisation is required. It is important to notice that the cost-effectiveness of a certain indicator depends on the baseline uptake. A first reason concerns the room for improvement. If there is already a high baseline achievement for a certain indicator, it is more difficult to reach an even higher score.
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