Pay for Quality

KCE Reports 118 Pay for Quality 107
6.4.2 What the future holds
All experts are convinced that P4Q will continue to exist in their country. The
Australian and Dutch experts think that P4Q in their country, which is currently still in
a starting phase, will gain importance.
They all agree it is important to attach research to the introduction of P4Q schemes.
On the whole the UK experience, in terms of a modest improvement in quality, is
probably consistent with US experience and other countries’ experiences, but ongoing
evaluation is necessary on the following items:
• There is a need for research on the optimal size of the incentives and
whether a bonus or a withhold or a combination is desired, on the level to
which incentives are paid (individual, group, organisation) and on rewarding
high achievement or rewarding improvement to improve care and to reduce
variation;
• There are still some questions about impact on patient experiences. It is
advised by the experts to focus more on patients and less on providers;
• It is important to do more research on unintended consequences, risk
adjustment, exception reporting and equity;
• The development of new sets of indicators is an ongoing process (process as
well as intermediate outcome measures);
• It is unsure what the effect of P4Q will be in the future. More research on
the permanent impact of P4Q on quality should be carried out;
• In most P4Q programmes more quality measures focused on primary care
(e.g. vaccination target, cervical smear target, diabetes targets) and less on
specialty care. It is a methodological challenge to develop specialty care
indicators for specialist and hospital care.
6.4.3 Conclusions
Most recommendations made by the experts are consistent with the ones resulting
from the evidence (see 4.4.3 Revising the conceptual framework based on evidence).
Only a few additional issues were cited by the experts. They agree that before
considering implementing P4Q programmes, the government as well as clinical
leadership should recognize the importance of quality and the variability of quality
between physicians. Later on, all stakeholders (insurers, government, health care
providers, and academics) should be included from the start in the negotiation process
of implementing P4Q. Furthermore the expert draw the attention on the fact that
indicators should be derived from evidence based criteria and that quality should be
targeted on those indicators that show a lack of quality. In addition, the providers have
to be involved in setting the indicators. The experts advise to strive to include process
parameters that have a clear and proven link with outcome. When setting the
indicators, not only underuse but also overuse should be targeted. Finally it is important
toe recognize that P4Q should be seen as one of many different quality initiatives, only a
combination of initiatives could lead to a quality improvement in the health care system
of a certain country or region.
Overall conclusion by the experts on quality improvement is that financial incentives are
modestly effective. Experts agree that P4Q programmes are no magic bullets, however
they can be of value, when organised in the right way. These programmes should be
seen as part of a range of quality improvement initiatives. Before developing a P4Q
scheme it is important to stipulate those areas where quality improvement is desirable.
Physicians should be involved in the developing process and in setting the indicators.
Experts agree that it would be wise to make use of a phased approach.