Pay for Quality

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98 Pay for Quality KCE Reports 118 6.2.2.3 Australia The last 20 to 25 years there has been a desire amongst Commonwealth Government in Australia to reduce the amount of money paid to general practices based on FFS and increase the amount of money that is paid at general practices on another basis than FFS. The government is trying to move away from simply rewarding production. Regarding the medical services in primary care, there is a Pay for Quality programme named the Practice Incentive Program (PIP), which is organized at a national level and applicable for all accredited general practices. 238 The incentives in the PIP project are paid by the commonwealth government. The incentives in the Queensland project are paid by the state. The government conducted some modelling exercises to make sure there was enough money to pay for the indicators. In both programmes participation is voluntary. Beside these P4Q programmes, 15 years ago a hospital accreditation programme was introduced in Victoria in which a small supplementary payment was provided. However this payment was not directly linked with quality. A number of states have incentive programmes regarding waiting lists and waiting times in hospital services. Currently there is only one state (Queensland) that has a real Pay for Quality programme for hospitals (the Clinical Practice Improvement Program g ). This P4Q programme was implemented as a result of a significant quality scandal in 2005 and aims at improving quality. About 16 quality of care indicators are included in the programme. Clinical networks, which are run by clinicians (cardiac network, mental network, etc) were involved in the development of these indicators. A number of health insurance funds have additional requirements on hospitals to undertake patient experience or patient satisfaction surveys, but hospital incentives aren’t directly linked to these indicators. 6.2.2.4 The Netherlands In the Netherlands P4Q has been initiated by the government. A first P4Q initiative was developed mid 1990’s. General practitioners were paid for influenza immunization of their patients, and for carrying out cervical smears amongst their eligible patients. Currently three Pay for quality initiatives in primary care can be distinguished in the Netherlands. 1°. The organization of care groups regarding certain disorders (for example diabetic care), in which participants are being paid based on the outcome on quality indicators. 2°. A second initiative is related to a practice accreditation programme of general practitioners. Participation in the programme, which consists of supplying information on clinical indicators, information on the organization of the practice and patients surveys, is being rewarded by a limited allowance. In the first year physicians get an accreditation for participation. After the first year general practitioners have to establish an improvement programme. In the second year accreditation can be obtained if physicians have acted according their improvement programme. 3°. A third initiative consists of a bonus programme developed on top of the accreditation programme. In this experiment there are about 75 voluntary health care providers and 2 voluntary private insurers. To start this experiment a restricted set of clinical indicators has been selected, related to 4 chronic diseases, prevention and medication use. Moreover, some patient experience indicators and management indicators are included. All indicators are being evaluated every year, except the management indicators, which are being evaluated every 3 year. The incentives are being paid by the health plans. Participation is voluntary, but this will change. The moment a new payment system will arise, participation will become mandatory. Currently, it is not clear yet if health plans will work with one coordinated P4Q programme in the future or if each of them will have their own P4Q scheme. g for more information see the following link http://www.health.qld.gov.au/cpic/
KCE Reports 118 Pay for Quality 99 Concerning hospital care, several public reporting initiatives are been implemented. Currently no P4Q programmes are yet been developed h . Key points on interventions UK • In the past several P4Q schemes have been launched in primary care. These initial P4Q schemes were limited in scope, but likely did improve cervical screening and immunisation rates over time. • In 2004, QOF has been introduced successfully in primary care. This P4Q programme targets clinical indicators, patient experience and practice organization. Recently a pilot P4Q scheme, called ‘advancing quality’ has been implemented in the North West of England. USA • The USA is characterized by its many different P4Q schemes, in primary care as well as in hospital care. Large employers put pressure on private insurers to initiate the first P4Q schemes. Currently, Medicare and more than half of managed care insurers, HMOs and PPOs, are using P4Q schemes. In California the IHA has successfully introduced a uniform, multipayer P4Q scheme. P4Q is only one of the activities used in the US to improve quality. Australia • Regarding hospital care there is only one P4Q programme, named the Clinical practice improvement programme that is implemented in Queensland. In primary care the Practice Incentive Program is introduced at national level. The Netherlands • Three P4Q programmes in primary care can be distinguished in the Netherlands. The organization of care groups, the accreditation programme of GPs, and a bonus pilot programme, which is developed on top of the accreditation programme 6.2.3 P4Q concepts 6.2.3.1 Quality In this section generic findings across the four countries will be discussed. Quality Dimension P4Q programmes are mostly initiated in response to the higher demand from government and insurers to deliver quality. All the experts agreed that effectiveness should be measured in any P4Q programme. However, there are some other domains that could be of use. According to some experts the inclusion of deprivation measures in P4Q programmes could be interesting (equity). Especially in the US, deprivation measures are not always included in P4Q programmes. However, there has already been a small effort in the US to reward providers who serve low income and racial/ethnic minority populations more for the same level of improvement. Nevertheless, it must be noted that some experts believe that P4Q is probably not the right source for improving health for minority groups. Other kinds of investments e.g. in public health sector may be a better way to improve health in minority populations. In the US there is also great concern about cost-containment. There exists a belief that not only quality but also efficiency gains have to be rewarded. To the extent that P4Q is being used to try to guide care towards more cost-effectiveness use, the underlying payment system will be determinative. h For more information see the following link: www.kiesbeter.nl
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