Pay for Quality

102 Pay for Quality KCE Reports 118
Individual physicians do not receive a bonus, but the group bonus may serve for
investing in the enhancement to the electronic health record, in case managers, etc. In
that sense, team care can be a better option. In the Queensland hospital P4Q project in
Australia, incentives go to the unit. In the Netherlands, incentives are targeted at the
practice level like in the UK. Most experts share the opinion that ideally, incentives
should be targeted at the provider unit or the practice group, and this gives the group
or the unit the possibility to invest in the practice (for example improving the IT
system). Incentives that are given on a higher level could create a moral hazard problem
because the individual incentive is less important and therefore the stimulus to perform
well dilutes.
Key points on P4Q concepts
Quality
• Experts agree that there are several other domains that could be of some
use to measure besides effectiveness, like equity, cost-containment and
timeliness. In most countries process measures are used. According to the
experts, process outcomes and intermediate outcome measures are
adequate measures to control quality.
• Concerning the collection of the data, they all agree that, data should be
extracted automatically out of the EHR.
Incentives
• In the UK, Australia and the Netherlands only bonuses are used in the P4Q
schemes. In the US both bonuses as withholds are used. In the UK financial
rewards generate approximately 25% of GP’s income. In the USA, only 1 to
2% of provider’s income is generated from the P4Q schemes, because of the
heterogeneity in the use of P4Q schemes.
• Experts agree that the incentive size should range between 5 and 25%.
• 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.
• Most experts share the opinion, that ideally, incentives should be targeted at
the provider unit or practice group, this gives the group the possibility to
improve quality by investing in the practice or organisation. Incentives that
are given on a higher level could create a moral hazard problem.
6.2.4 Implementing and communicating the programme
6.2.4.1 Involvement of providers
The introduction of the QOF system in 2004 was a result of an 18 months lasting
negotiating period between the government, the British Medical Association and
academics. It was a consensual process that went trough a vote. The targets set in the
first QOF version were easily reached. The QOF scheme is large and complex and was
never intended to stay static. It is a process of updating and adapting indicators which
has to be done by academics in association with the British Medical Association and the
government. As a consequence in the most recent revision, indicators that weren’t
worthwhile were deleted or changed after negotiation. This process of indicator
development is to be taken over by the National Institute for Health and Clinical
Excellence (NICE).
In the Netherlands, the P4Q scheme is also a result of a negotiation process between all
stakeholders, and the indicators were chosen in dialogue with the physicians. In
Australia, clinical networks, which are run by commissions (cardiac network, mental
network, etc) were involved in the development of these indicators.