Pay for Quality

More documents

Recommendations

Info

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.
KCE Reports 118 Pay for Quality 105 It must be noted, that the QOF system, which consists of one coordinated programme, makes innovation difficult. The included indicators in a P4Q programme make it difficult for providers, to implement for example new treatment methods or new chirurgical methods. In US on the contrary, all the different P4Q schemes make developing and implementing innovations easier. Key points on evidence • According the experts financial incentives are modestly effective in improving quality. They all agree that P4Q is no magic bullet; however P4Q programmes could have value if organised and implemented in a correct way. • The programmes should be seen as part of a range of quality improvement activities. • Concerning the unintended consequences until now not mush evidence was reported. There is some evidence that equity is probably improving, however it is hard to asses whether this is the result of P4Q or caused by a secular trend. According to the experts monitoring of unintended consequences remains important. 6.4 DISCUSSION AND CONCLUSION 6.4.1 Key recommendations for design and implementation To successfully implement a P4Q programme, peculiarities of health system need to be taken into account. The context in which P4Q is being introduced is very different in different parts of the world, so this makes it hard to generalize. The experts suggested the following recommendations for a country at the first initial stage of considering the implementation of P4Q: Quality goals and targets 1. Be clear about what the priorities and objectives are. It is important to consider which domains to include in the P4Q system: it should be feasible, payable, and lead to better quality. For example financial incentives may be not appropriate in the patient safety domain This domain is probably best covered by for instance critical incident analysis, when things went wrong 2. Indicators should be derived from evidence based criteria and the health care providers should be included in setting the indicators. Chose indicators where there is still room for improvement; 3. Include different quality domains in the P4Q programme: effectiveness, deprivation measures, timeliness, cost-effectiveness 4. Do not only focus on underuse but also on overuse in health care; 5. Include a sufficient amount of measures. To few measures can lead to “teaching to the task” (physicians only focus on incentivized indicators and ignore the unincentivized indicators); 6. Strive to include process parameters with a clear and proven link with outcome; 7. Organisational indicators are of limited value although some could be important, e.g. if one is aware of problem areas with major problems, e.g. it is impossible for disabled people to get access to surgeries because they are only to reach by means of the staircase; 8. Measure unintended consequences.
Page 1 and 2:
Voordelen, nadelen en haalbaarheid
Page 3 and 4:
Voordelen, nadelen en haalbaarheid
Page 5 and 6:
Externe validatoren : Simpson (Univ
Page 7 and 8:
KCE Reports 118A Pay for Quality ii
Page 9 and 10:
KCE Reports 118A Pay for Quality iv
Page 11 and 12:
KCE Reports 118A Pay for Quality vi
Page 13 and 14:
KCE Reports 118A Pay for Quality vi
Page 15 and 16:
KCE Reports 118 Pay for Quality 1 S
Page 17 and 18:
KCE Reports 118 Pay for Quality 3 9
Page 19 and 20:
KCE Reports 118 Pay for Quality 5 W
Page 21 and 22:
KCE Reports 118 Pay for Quality 7 S
Page 23 and 24:
KCE Reports 118 Pay for Quality 9 2
Page 25 and 26:
KCE Reports 118 Pay for Quality 11
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38:
Page 39 and 40:
Page 41 and 42:
Page 43 and 44:
Page 45 and 46:
Page 47 and 48:
Page 49 and 50:
Page 51 and 52:
Page 53 and 54:
Page 55 and 56:
Page 57 and 58:
Page 59 and 60:
Page 61 and 62:
Page 63 and 64:
Page 65 and 66:
Page 67 and 68: KCE Reports 118 Pay for Quality 53
Page 77 and 78: Clinical domain (disease) KCE Repor
Page 117: KCE Reports 118 Pay for Quality 103
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191:
Page 194 and 195:
Wettelijk depot : D/2008/10.273/50
Page 196 and 197:
37. HTA Magnetische Resonantie Beel
Page 198:
108. Tiotropium in de behandeling v
show all

Pay for Quality

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?