Pay for Quality

88 Pay for Quality KCE Reports 118
Secondly, if baseline uptake is high, the mean absolute change in utilisation needed for
an indicator to be cost-effective needs to be larger than when the baseline uptake is
low, because physicians also receive an incentive for those patients for whom the target
was already reached and no additional health benefits have been achieved. As a result a
high absolute change (and thus a high additional health gain) is required to compensate
for the payments without extra health gain. It must also be noted that cost-effectiveness
of an indicator will be partly determined by the duration of the P4Q programme. To be
cost-effective it is desirable to adjust the payment according to the observed utilisation
levels throughout time.
We can conclude that P4Q programmes seem to be cost-effective. It can be stated that
implementing indicators with a low baseline achievement, have the highest potential to
be cost-effective. Since these conclusions are based on only three studies, it is
recommended to augment the number of cost-effectiveness evaluations of P4Q
programmes in the future.
Kahn et al. (2006) 229 modelled the financial gains and losses for hospitals, using two
P4Q programmes. In both programmes, urban hospitals are more likely to attract
bonuses as well as to get penalties resulting in a financial gain in one programme and a
small financial loss in the other programme. Rural hospitals, receive less bonuses, but
also less penalties, resulting in a small financial gain in both programmes. Teaching
hospitals are more likely to have a financial gain unlike non teaching hospitals, which
receive a larger amount of bonuses but also get more penalties, resulting in a small
financial loss in both programmes. Finally government and investor-owned hospitals are
more likely to suffer a financial loss, in contrast to tax-exempt hospitals that are more
likely to experience a financial gain.
The payment reduction, as a result of a new inpatient prospective payment system was
estimated by Averill et al. (2006) 95 . The new system provides hospitals with a financial
incentive to reduce complications and to improve the quality of care. This resulted in a
reduction of the Medicare DRG hospital payment with approximately 1%. These savings
have the potential to increase payments to high performing hospitals.
According to Fleetcroft et al. (2006) 227 , QOF payments don’t reflect likely health gain.
The use of ACE inhibitors in heart failure relates to a maximum of 308 lives saved per
100 000 people per year and is linked to a maximum payment of £2 400 per practice
per year. In contrast the screening and treatment of hypertension only saves a potential
maximum of 71 lives per 100 000 people per year but costs on average £17 280 per
practice per year.
As a result the GPs might focus on the highly rewarded indicators with sometimes
relatively low population health gain.
McElduff et al. (2004) 228 estimated the health gain among cardiovascular disease (CVD)
patients within QOF. Reaching the target concerning cholesterol-level and hypertension
would result in important reduction in number of CVD events. Fleetcroft et al. (2008)
226 , 228 confirm the potential for significant health gain regarding clinical indicators. The
difference between actual health gain and potential health gain can be explained by
several determinants among which the room for improvement (baseline activity) and
the prevalence of conditions or associated event risk. Additionally, the possibility of
exception reporting within QOF reduces the potential maximum health gain.
Furthermore, better recording rather than actual improved performance could increase
the achievement. Gaming among practitioners could also influence the health gain. The
health gain in patients with multiple conditions may be less or more than the sum of the
beneficial effect of each intervention. And, finally, some indicators have potential side
effects, which could reduce health gain (e.g. adverse events of some drugs).