Pay for Quality

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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).
KCE Reports 118 Pay for Quality 89 5.2.3 Reported impact of P4Q on equity (In)equity in health care is a central point of attention of many health care systems and tackling this inequity has been an important objective in the development and reorganization of health services. 63 There is widespread concern that the focus on quality improving systems driven by financial incentives may lead to a widening of the existing inequity in health care. Within this report the impact of the introduction of the Quality and Outcome Framework in the UK on equity in treatment and (intermediate) outcomes was investigated. More specifically with this study we want to target the following three sub domains: the immediate effect of the implementation of QOF on the existing inequity in treatment and (intermediate) outcomes, the effects on long term and the contribution of exception reporting in treatment and (intermediate) outcomes. Several limitations in the selected studies complicate the formulation of the evidence, prompting utmost prudence in interpreting and generalizing the results of this study. In the assessment of equal access to care it is essential to look for differences in social or ethnic background, gender … between the users of health care and the non-users of health care, both with the same need for care. None of the studies addresses this issue: they do not include information on the ratio users/non-users (both in equal need for care) and on the variation in the characteristics of the users and the non-users. This makes it impossible in this study to pronounce upon overall equity in access. The majority of the studies make no judgments about the appropriateness of the indicators or the treatment targets for both groups. As a result, similar screening or treatment rates can actually mean under treatment of certain groups, hence inequity 63 .In none of the selected studies normative need, felt need or expressed need is taken into consideration when observing differences in treatment and/or (intermediate) treatment outcomes. In the majority of the studies the authors (inexplicitly) adopt a comparative approach to need: when variations are found between the treatment rates and outcomes of two groups of patients with the same condition (e.g. low-income versus high-income diabetic patients), inequity is presumed. Characteristic of a comparative approach of need is that it makes no judgments about the appropriateness of the indicators or the treatment targets for both groups. E.g. when no differences are found in the cervical screening rates between population A and B most of the selected studies would presume equity. However knowing some groups have a higher risk on cervical cancer related to number of sexual partners, similar screening rates actually mean under treatment of this second group and so inequity. As a result utmost prudence is necessary when interpreting the results of the studies: the absence of social, gender or age differences should not automatically be interpreted as absence of inequities. 63 Questions can be asked about the relevance and the completeness of the indicators that are used to measure quality. Although initiatives such as the QOF cover many important aspects of quality of care, the inherent strength and complexity of the doctor-patient relationship supports quality at a much deeper level which is not captured by the QOF indicators. The same reasoning applies to the fact that the selected publications mainly focus on intermediate outcomes and less on final outcome measures. To what extent equity in intermediate outcomes or process indicators predict final outcomes, not to speak to what extent the found (in)equities in health care predict (in)equities in health? The selected studies have weak study designs according to the labels presented in chapter 4. Of the 27 studies studying the pay-for-performance initiative in the UK • 17 have a cross-sectional design with only one point of measurement; • 7 studies have a serial cross-sectional design with several points of measurement in time (of which only 3 with both measurements before and after the introduction of the new initiative) • 3 studies have a longitudinal design with several points of measurement in time and linking of the data from the same study subject (e.g. patient) over time
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