Pay for Quality
Pay for Quality
Pay for Quality
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100 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> KCE Reports 118<br />
For example in a health care system based on a fee <strong>for</strong> service system, it will be difficult<br />
to diminish <strong>for</strong> example the MRI use with a small bonus, because physicians can earn<br />
much more than the amount of the bonus by carrying out an unnecessary MRI. This is<br />
of course directly related to decisions on the size of the reward. Concerning costeffectiveness<br />
one US experts fears that people will find quality not that important as<br />
cost. In Australia and also in the Netherlands more recently, there is also a great focus<br />
on timeliness. There are financial incentives to reduce waiting time <strong>for</strong> patients <strong>for</strong><br />
surgery and <strong>for</strong> waiting times in the emergency room.<br />
<strong>Quality</strong> Indicators<br />
In most P4Q programmes mainly process measures are been used, as these indicators<br />
can be influenced within small periods of time and within limited time frames. It is also<br />
believed that process measures are in the control of physicians. According to one US<br />
and one UK expert it is important to have outcome measures because achieving a<br />
process measure does not necessarily result in a better health outcome. Intermediate<br />
outcome measures would be adequate, because these measures can be linked to certain<br />
hard outcomes. Others (UK, NL) believe process measures are sufficient to measure<br />
per<strong>for</strong>mance, on the assumption that improved process measures will lead to better<br />
health care outcome.<br />
Current programmes initially target underuse. However a lot of health care systems are<br />
confronted with overuse and misuse, there<strong>for</strong>e targeting this in P4Q programmes can<br />
be useful. Recently the measures <strong>for</strong> overuse and misuse are rising, and the focus within<br />
P4Q programmes is changing from underuse to overuse.<br />
In the UK exception reporting is allowed, this enables providers to exclude individual<br />
patients from the calculations <strong>for</strong> specific targets, because there was a valid reason <strong>for</strong><br />
not reaching the target in that individual patient, which was not related to quality of<br />
healthcare. Most experts agree that it would be useful to include exception reporting in<br />
a P4Q programme.<br />
<strong>Quality</strong> measurement<br />
In the UK, clinical indicators are automatically extracted out of the electronic health<br />
records by the government.<br />
In the US, P4Q data are largely based on billing data. Physicians complain that billing data<br />
(“claims data”) aren’t rich enough to capture quality. However, according to experts,<br />
billing data are sufficient <strong>for</strong> process measures. For outcome measure on the contrary,<br />
clinical data is necessary.<br />
In Australia the data collection system is very transparent and there seems to be<br />
sufficient trust among health care providers. Some of the data are collected manually.<br />
Concerning the PIP programme in general practice, data is provided to Medicare<br />
Australia. Related to the data collection within this programme there have been<br />
complaints concerning the different computer software programmes and about the<br />
amount of paperwork.<br />
In the Netherlands, electronic health records are available, but not all indicators<br />
included in the P4Q scheme are comprised in the files. Physicians need to complement<br />
these data with other data that have to be introduced manually in the data system. Data<br />
are collected at the practice level and send to health insurers by GP organisations <strong>for</strong><br />
additional payments.<br />
According to the experts, collecting data manually is too time-consuming. The experts<br />
agree that the data should ideally come out of the work flow through electronic health<br />
records. All were convinced that data collection just <strong>for</strong> the purpose of P4Q is not a<br />
desired way of collecting data.<br />
Risk adjustment<br />
Experts believe that risk adjustment, where the provider’s case-mix is taken into<br />
account, may not be necessary if one focuses on process measures, and that it is only<br />
necessary if the focus is on outcome measures.