Pay for Quality

92 Pay for Quality KCE Reports 118
In England, rates of exception reporting have generally been low, with little evidence of
widespread gaming” 84 . However, it can be argued that nevertheless the exclusion
system succeeds in not being socially selective, it does not succeed in rewarding the
additional work required in deprived areas 230 .
In general, hopeful results were found. It can be states that after the introduction of the
QOF at least some of the existing inequities became smaller and the positive effects
seem to continue over the years. Still it is important to keep in mind that equity in
health care is just a small piece of the larger jigsaw of determinants explaining inequity in
health.
5.2.4 Revising the conceptual framework based on evidence
In this section not all of the findings as presented before in section 5.1 (page 71) will be
repeated. Here only a summarized overview of the most important do’s and don’ts is
discussed. The same notation of levels of evidence is used (‘S’ = strong evidence, ‘W’ =
weak evidence, ‘C’ = conflicting evidence, ‘N’ = no evidence). In the case of conflicting
evidence or an absence of evidence, the recommendations are based on theoretical
grounds.
5.2.4.1 Quality goals and targets
5.2.4.2 Quality measurement
5.2.4.3 P4Q incentives
1. Take all SMART aspects into consideration when selecting targets (including
relevance and timeliness). (S)
2. Measure potential unintended consequences (especially in care equity, patient
experience and provider experience). (S)
3. Consider both appropriate and inappropriate care, as both cannot be
separated. (C)
4. In short term, make use of structure, process, and intermediate outcome
indicators. Each of these indicator types has their own value (e.g. IT adoption
enhancement as a structural goal). (S)
5. Keep the number of targets feasible and transparent, but also sizeable within
the full scope of delivering healthcare. (S)
6. Make use of a cyclical and dynamical quality improvement approach. (S)
1. Make use of validated data already available as much as possible. (N)
2. Provide an audit system to prevent and detect gaming. (N)
3. Apply case mix adjustment on intermediate outcome measures. (S)
4. Apply exception reporting to guard individualized care. (W)
1. Make use of a non competitive approach (C). Budget equilibrium can be
guarded alternatively by applying a corrective factor on all P4Q incentive
payments, equal in size for all participants (N).
2. Make use of rewards. Punishments can be reserved for gross negligence (N).
3. Reward both best performers and best improvers (N).
4. Follow theoretical indications about a sufficient incentive size (about 10% of
total payment), since evidence is still inconsistent (C).
5. Provide free choice to providers to use the incentive to invest in quality or to
increase income (see QOF example) (S).
6. Align the complexity of the system with the complexity of healthcare
delivery. Use more transparent and clear means to communicate the
incentive drivers to providers. (S)
7. Weight targets in short term in function of related workload and according
to target type (structure, process, and outcome). Add in long term the
related cost savings to this equation. (S)