Pay for Quality

KCE Reports 118 Pay for Quality 95
Figure 10: Revision of the MIMIQ model
Quality
Different (7) possible Quality 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 for relevant and timely, based on room for improvement within a dynamical
aproach
Quality 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
Quality of the communication
Targeted or widespread communication: High
importance of direct and intensive provider
communication (S)
Payer 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 information 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 information 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 performance 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 reinforces 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 for 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 performance (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 information 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 for 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 for initially low performers (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 performance 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 performance (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 performance 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)
Information 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)