Pay for Quality
Pay for Quality
Pay for Quality
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104 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> KCE Reports 118<br />
6.3 EVIDENCE<br />
6.3.1 Likely effect according to the experts<br />
For the UK there is clear evidence that quality has improved somewhat as a result of<br />
the introduction of P4Q. However in 2005 further improvement slowed down. In the<br />
US there is probably a modest positive effect (1-2%) but not across all programmes.<br />
Because most P4Q programmes are natural experiments without a control group (US,<br />
UK, Netherlands), it is unclear if the effect can be assigned to P4Q alone. There are a<br />
lot of co-interventions like public reporting etc. Furthermore it is mostly unknown in<br />
what direction not incentivized quality indicators have evolved, an underlying trend of<br />
improving quality is assumed by most of the experts. In the Netherlands the first results<br />
show an improvement on clinical indicators (around 10%) and on patient experiences<br />
(around 5%), here too it has to be noted that there was no control group and<br />
moreover there were some co-interventions like accreditation.<br />
All experts agree that P4Q programmes are no magic bullets. Overall it seems that<br />
financial incentives are modestly effective. P4Q programmes could have some value it<br />
they are organised in the right way, however, these programmes should be seen as part<br />
of a range of quality improvement initiatives. Other quality initiatives can be: investing in<br />
quality training of physicians and learning them to be more pro-active, investing in<br />
electronic health records and trans<strong>for</strong>ming practices to be more efficient (e.g. financing<br />
IT investment). In the US, Kaiser Permanente, which is a medical group, has moved<br />
down this path quite successfully, with physicians support, and with Electronic Health<br />
Records. 239 For instance, when scheduling an appointment the system prompts the<br />
physician <strong>for</strong> conducting recommended tests, and it sends lab results electronically to<br />
the patients. There is a high focus on standardizing the delivery of care, and hence<br />
reducing variability.<br />
In a sense P4Q is a response to a lack of patient activation and patient recognition<br />
about what kind of care they should demand. Consequently, insurers and governments<br />
should do well to figure out ways to make patients more engaged in demanding effective<br />
and cost-effective care <strong>for</strong> themselves.<br />
6.3.2 Unintended consequences according to the experts<br />
Until now, not much evidence of unintended consequences was reported. However,<br />
there is some evidence that equity is probably improving in the UK, i.e. the gap between<br />
deprived areas and not deprived area rose until 4.5 to 5% in the first year of P4Q and<br />
has now narrowed to 0.5%. However is it hard to asses whether this is a result of P4Q<br />
or caused by a secular trend. There is also evidence that inequalities in chronic disease<br />
management between ethnic groups have not been attenuated. Additionally, there<br />
seems to be no negative effect on access and patient experiences.<br />
Yet, according to the experts there are some topics which should be monitored closely<br />
in any P4Q programme. These topics include:<br />
<strong>Quality</strong> indicators that weren’t incentivized are likely to get less attention and may have<br />
gotten worse.<br />
Absence of a control system could provoke gaming of the system, especially when the<br />
incentive size is quite high. It must be noted that gaming is a real threat, and even a<br />
control system might not always capture those who game the system.<br />
It is assumed by some experts, that difficult patient groups are probably concentrated in<br />
some practices. Those practices get paid less overall and end up with fewer resources.<br />
This can be a paradoxical effect of P4Q.<br />
Big and powerful physician groups are probably better in negotiating better prices,<br />
leaving individuals and small groups to lag behind.<br />
Some experts fear some reduction on continuity and coordination of care. There is a<br />
tendency to take care out of routine care into special clinics (e.g. diabetes clinics) which<br />
effective method to make sure all checks are done. Consequently, the patient<br />
potentially sees more people in practice.