94 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> KCE Reports 118 5.2.4.8 Patient characteristics 1. Monitor the effects of patient age, gender, socio-economical status, ethnicity and number of co morbidities on P4Q results. (W) 2. Take into account the experience of the patient as part of the targets, and during programme development, implementation and evaluation. (N) 3. Take into account patient influence when selecting targets and defining exception reporting criteria. (S) 5.2.4.9 Revision of the MIMIQ model Figure 10 resumes the conceptual model that was presented in chapter 3. However in this version the results from the literature study are incorporated. For each item from the model, the strength of the evidence and the direction of the evidence are indicated. However, it must be noted that <strong>for</strong> those items, where no evidence can be found yet, there might be still good theoretical reasons to take them into account when implementing a P4Q programme: no evidence does not necessarily mean no desirable effect. In Figure 10, this is <strong>for</strong>mulated as ”best use of theoretical guidance”.
KCE Reports 118 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> 95 Figure 10: Revision of the MIMIQ model <strong>Quality</strong> Different (7) possible <strong>Quality</strong> dimensions: Effectiveness (S),Equity and access (W),Integration and coordination (W),Provider experience (W),Generic applications (W),Other domains (N) Structure, process, and/or outcome indicators: Structure (S),Process (S),Intermediate outcome (S),Long term outcome (W) Number of targets and indicators: Not too few (S) SMART targets: A lack of attention <strong>for</strong> relevant and timely, based on room <strong>for</strong> improvement within a dynamical aproach <strong>Quality</strong> measurement Data source and validity: No difference in clinical results (S), Other domains (N) Case-mix: A lack of distinction between study and program risk adjustment utilization Exception reporting (W) Unintended consequences: At present not identified (W) Communicating the program Communication to whom (providers, patients, ...): High importance of provider communication and awareness (S) Detail and terminology of the communication <strong>Quality</strong> of the communication Targeted or widespread communication: High importance of direct and intensive provider communication (S) <strong>Pay</strong>er characteristics Mission/Vision of the payer: Lack of reporting (N) Typology (Private/public/mixed): Scarce reporting of an absence of effect of these differences (W) Current use of clinical guidelines: lack of reporting (N) Variable patient contribution: Lack of reporting in USA (N). In other countries no variable patient contribution Other incentive programs running: Important influence of a dilution effect by other incentive programs when not aligned (W) Availability of in<strong>for</strong>mation systems: The different approaches do not translate into differences in clinical effect (S). Lack of reporting in the included studies of payer and provider work experience effects (N). Number of payers: see importance of dilution effects (W) Accuracy of in<strong>for</strong>mation system: Use of sufficient validity safeguards in most studies. Evidence of gaming by providers to a very limited degree (W). Implementing the program Involvement of providers in setting goals: Lacking and conflicting evidence, best use of theoretical guidance (C, N) Mandatory or voluntary participation: Conflicting evidence, best use of theoretical guidance (C), No evidence of selection bias in terms of per<strong>for</strong>mance history due to voluntary participation (W) Staged approach of implementation: Modelling and piloting can prevent unexpected budgetary effects (S) Stand alone P4Q program or embedded in a broader quality project: A bundled approach rein<strong>for</strong>ces the P4Q effects (S) and serves as a recognition of the full spectrum of non financial quality improvement initiatives & Provider characteristics Awareness, perception, familiarity, agreement, self-efficacy Other motivational drivers: Lack of reporting (N) Medical leadership, role of peers, role of industry: Lack of reporting (N) Existence/implementation of guidelines, room <strong>for</strong> improvement: Lack of reporting (N) Level of own control on changes: Lack of reporting (N), but in almost all studies (except smoking cessation studies) controllable measures were targeted. In addition most studies use intermediate instead of long term outcome targets. Target unit (individual, group/organisation, …) and size: Evidence of positive effects on the individual and/or team level (S), Conflicting evidence on the level of an organization (medical group, hospital) and on the level of leadership (C). In case of not-individual, size of unit (# providers): Conflicting evidence on solo vs. group practice per<strong>for</strong>mance (C), Positive relationship with the number of providers within a practice (W), No relationship with hospital size (W) Role of the meso level (principal or agent): Lack of reporting (N) Demographics (age, gender, specialty,…): Significant effect of provider age, gender, training background, geographical location, and having a second specialty (W), No significant effect of provider experience and rural vs. urban location (W) Organisational resources available and in<strong>for</strong>mation systems: Weak evidence on the influence on P4Q effects, as measured through hospital/medical group/IPA status, age of the group or organization, organization vs. individual ownership, and teaching status of an organization (W) Organisational system change and extra cost/time required: Lack of reporting (N) Number of patients and services per patient: Conflicting evidence (C) Room <strong>for</strong> improvement: Strong evidence on the influence on P4Q effects (S) Health care system characteristics Values of the system Type of system (e.g. insurance or NHS) Level of Competition Decentralisation of decision making and therapeutic freedom Dominant payment system (FFS, salary, capitation, ...) Incentives Incentive structure: Lack of evidence on diverse options, best use of theoretical guidance (N) Threshold value and/or improvement: In both a larger effect size <strong>for</strong> initially low per<strong>for</strong>mers (S) Weight of different quality targets: Weighting according to target specific workload and according to sets of target types (S), Conflicting evidence on composite or all or none measures (C) Size (net additional income achievable): Conflicting evidence, best use of theoretical guidance (C) Frequency: Conflicting evidence, best use of theoretical guidance (C) Relative or absolute (competitive or not): Conflicting evidence, best use of theoretical guidance (C) Stable and long enough: Lack of evidence due to current P4Q initiation phase (N) Simplicity and directness: No apparent negative effect of back office complexity, when combined with front office simplicity (S) Evaluation of the program Sustainability of change: Target per<strong>for</strong>mance does not regress while being incentivized (S), There is an upper limit on target specific quality improvement (S),Lack of evidence on post P4Q target per<strong>for</strong>mance (N) Validation of the program: Evaluation is confirmed in peer reviewed literature (S),Lack of evidence on the use of evaluation in programs with absent or elsewhere reporting (N) Review and revising the process: Too early stage and/or insufficient use of continuous iterative quality improvement cycles Financial impact and return on investment: see cost effectiveness results Patient characteristics Demographics, Co-morbidities: Closing per<strong>for</strong>mance gap with regard to patient age and unclear result with regard to gender, and ethnicity (W) Socio-economics, Insurance status: Unclear results with regard to socio economical deprivation level (W), Lack or reporting on the influence of insurance status (N) In<strong>for</strong>mation about price and/or quality: Conflicting evidence on the interaction of P4Q with public reporting (C) Patient behavioural patterns (cultural and consumer patterns, compliance): Lack of reporting (N)
Change language