Pay for Quality

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