Pay for Quality

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100 Pay for Quality KCE Reports 118 For example in a health care system based on a fee for service system, it will be difficult to diminish for example the MRI use with a small bonus, because physicians can earn much more than the amount of the bonus by carrying out an unnecessary MRI. This is of course directly related to decisions on the size of the reward. Concerning costeffectiveness one US experts fears that people will find quality not that important as cost. In Australia and also in the Netherlands more recently, there is also a great focus on timeliness. There are financial incentives to reduce waiting time for patients for surgery and for waiting times in the emergency room. Quality Indicators In most P4Q programmes mainly process measures are been used, as these indicators can be influenced within small periods of time and within limited time frames. It is also believed that process measures are in the control of physicians. According to one US and one UK expert it is important to have outcome measures because achieving a process measure does not necessarily result in a better health outcome. Intermediate outcome measures would be adequate, because these measures can be linked to certain hard outcomes. Others (UK, NL) believe process measures are sufficient to measure performance, on the assumption that improved process measures will lead to better health care outcome. Current programmes initially target underuse. However a lot of health care systems are confronted with overuse and misuse, therefore targeting this in P4Q programmes can be useful. Recently the measures for overuse and misuse are rising, and the focus within P4Q programmes is changing from underuse to overuse. In the UK exception reporting is allowed, this enables providers to exclude individual patients from the calculations for specific targets, because there was a valid reason for not reaching the target in that individual patient, which was not related to quality of healthcare. Most experts agree that it would be useful to include exception reporting in a P4Q programme. Quality measurement In the UK, clinical indicators are automatically extracted out of the electronic health records by the government. In the US, P4Q data are largely based on billing data. Physicians complain that billing data (“claims data”) aren’t rich enough to capture quality. However, according to experts, billing data are sufficient for process measures. For outcome measure on the contrary, clinical data is necessary. In Australia the data collection system is very transparent and there seems to be sufficient trust among health care providers. Some of the data are collected manually. Concerning the PIP programme in general practice, data is provided to Medicare Australia. Related to the data collection within this programme there have been complaints concerning the different computer software programmes and about the amount of paperwork. In the Netherlands, electronic health records are available, but not all indicators included in the P4Q scheme are comprised in the files. Physicians need to complement these data with other data that have to be introduced manually in the data system. Data are collected at the practice level and send to health insurers by GP organisations for additional payments. According to the experts, collecting data manually is too time-consuming. The experts agree that the data should ideally come out of the work flow through electronic health records. All were convinced that data collection just for the purpose of P4Q is not a desired way of collecting data. Risk adjustment Experts believe that risk adjustment, where the provider’s case-mix is taken into account, may not be necessary if one focuses on process measures, and that it is only necessary if the focus is on outcome measures.
KCE Reports 118 Pay for Quality 101 6.2.3.2 Incentives Size Different incentive structures are being used. The UK makes only use of financial rewards and approximately 25% of the practitioner’s income is generated by the QOF. This large investment has led to improvements in quality. However it remains unclear whether the quality improvement seen to date was worth the investment. The US makes use of both financial rewards (bonuses) and withholds. In the US the incentive size ranges between 2 and 10% of the payments, however only 10 to 20% of the payers are involved, consequently 1 or 2% of provider’s income are generated from P4Q schemes, leading to a dilution effect. Another example of an incentive is based on the difference in performance measure between different health plans in counties with more than one health plan, as assessed by Medicaid. Initially, when there was not as much money to pay bonuses, new Medicaid enrolees who did not select a health plan would be assigned to a better performing health plan at a ratio that reflect the quality of that plan in comparison to other plans. This is a financial incentive in the sense that there is financial gain for the organization having people come to their plan. Withholds are mostly used when programmes have to be budget neutral. The difference between a bonus and a withhold is somewhat semantic in the US. A withhold mostly consist of giving only a part of the money physicians or hospitals normally get. The remaining part is only being given if physicians or hospitals performing well. It can be interpreted as a withhold in the sense that physicians and hospitals were expecting to get that money. A withhold can also consist of ‘shared savings’, for example to reduce overuse. When healthcare overuse can be reduced, costs and consequently the physician’s income will also diminish, subsequently this saved amount of money is being divided between government and physicians, so physicians lose only half of the original reduction of income. Finally, another kind of withhold is being used in a hospital care P4Q related system by CMS concerning preventable complications. When hospitals submit their bill (consisting of all diagnoses a patient has had at discharge), the potentially avoidable complications can’t be included in the list of diagnoses. In this context it should be noted, that it is advised to develop audit systems to select fraud. In the UK, the P4Q system is not competitive. In the US on the contrary, P4Q systems are often competitive. According to one UK expert there is no justification for competition, rewards should relate to the levels of performance. In the Australian P4Q programmes discussed above, incentives are presented as financial rewards. In the Netherlands the P4Q pilot programme also only make use of bonuses, although as a consequence of the limited budget, insurances have difficulties to pay out these bonuses. As a result of the new insurance law a new payment system based on the delivered quality is in development. It is not yet clear how this new payment system will be organized and if the modalities of the above discussed pilot project will be incorporated. Some experts (US, UK, NL, AUS) argue that the incentive size in the US is probably too small and the size in the UK is too high. According to the experts the ideal incentive size should range between 5% and 25% of physicians income. An incentive that is too high could provoke gaming effects, an incentive that is too low on the other hand could limit the impact in terms of quality improvement. Target In the UK practices are owned by groups of GPs and QOF incentives are targeted at the practice level. The GP team can decide to invest the incentive in the practice and hence trying to improve quality even more or to divide the incentive between GPs. The hospital P4Q demonstration project which has been implemented recently in the North West region of the UK, targets its incentives at the department. In the US, team care almost doesn’t exist, therefore payments are often targeted at the individual. However, in the Californian IHA for example, project payments are made to very large multidisciplinary medical groups.
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