Pay for Quality

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110 Pay for Quality KCE Reports 118 Belgium is a country with a high access level of patients to healthcare and almost universal compulsory health insurance coverage (99%). Currently the level of gate keeping is minimal. Patients are free to chose which provider (GP, specialist, hospital) they consult, without restrictions. The basic right to health care has been set out in the Belgian Constitution. Patients participate in healthcare financing via co-payments, for which the patient pays a certain fixed amount of the cost of a service, and via co-insurance, for which the patient pays a certain fixed proportion of the cost of a service (10 to 40%). A maximum of outof-pocket expenses is safeguarded. Competition in the Belgian health system operates mainly through the competition for patients between providers and the competition for members between sickness funds. A typical characteristic of the Belgian health system is the participation of several stakeholders in its management. An important part of the health system is regulated by national collective agreements made between representatives of health care providers and sickness funds. Since the mid 1990s attention for the quality of healthcare in Belgium has increased. Quality control is applied by the government through accreditation of healthcare institutions (Hospital Act), accreditation of providers, peer review, audit and visitation. Hospitals report to the federal government (colleges of physicians) on their quality status on a yearly basis. The regional government of Flanders requires healthcare institutions to implement a quality manual, plan and evaluation cycle as part of accreditation conditions. In addition, specific campaigns address issues such as hand hygiene, antibiotics use, etc. Based on the conclusions and recommendations of the previous chapters the Belgian healthcare system, payer, provider and patient characteristics seem to fit with P4Q in the following way: There is strong evidence (next to international expert support) of the importance of the uniformity of the P4Q design, independent of the identification of P4Q initiators and coordinators. In this respect the concurrent levels of regional and national healthcare jurisdictions may pose a threat. The same risk is present at the level of the six sickness funds as purchasing/payer organizations. They are however united as part of RIZIV representation. With regard to P4Q implementation in Belgium a clear consensus based, all stakeholder inclusive approach is recommended, including complementation of the regional and federal level. This enables a combined centralized and decentralized (e.g. local priority setting based on room for improvement) decision making process. Multiple incentive programmes at the payer level should be aligned. With regard to the level of competition the low level of patient volatility in Belgium will support P4Q on the one hand. P4Q is not reinforced by consumer driven healthcare on the other hand. Incentive theory states that P4Q targeting underuse fits with a dominant FFS payment system. It’s therefore a reinforcement of the P4Q effect on this type of targets. Vice versa it may pose a threat to the P4Q effect on overuse targets. However, many of these overuse targets (medical imaging, clinical biology, etc.) are increasingly reimbursed as fixed payments, which diminishes this threat. In terms of provider characteristics specifically for hospital care the current focus of legislation, financing and quality management at the organizational level may pose a threat to P4Q targeting individual providers and/or team members. Such direct targeting in Belgium requires specific attention in P4Q regulation. Finally, with regard to patient characteristics the use of case mix adjustment at various levels of the Belgian healthcare system can be leveraged. However, more specific attention for the patient’s role is needed (equity, knowledge and involvement, experience of care, behavioural patterns, etc).
KCE Reports 118 Pay for Quality 111 What kinds of P4Q applications currently are available in Belgian healthcare is not clear. Nor is it currently known how current components of the central quality circle might fit with P4Q development, implementation and evaluation. Knowing this would further answer the question about practical feasibility of P4Q in Belgium. Therefore chapter 7 consists of two main parts. Section 7.1 focuses on the content of current quality and pay for quality initiatives in Belgium as a starting point. It offers a description of various quality initiatives and the extent to which they fit with a P4Q definition. Section 7.2 studies feasibility by positioning quality initiatives within the empirically revised conceptual P4Q framework. This allows the identification of current strengths and weaknesses of Belgian quality support and how this translates into opportunities and threats for P4Q implementation. Chapter 7 addresses, together with chapter 8, the following research questions: What are the conditions to apply international P4Q models or to enlarge Belgian quality improving experiments? Design, implementation, evaluation. What are the current initiatives in Belgium in the public and private sector to enhance quality of care by way of financial incentives linked to quality of care measures? Is there any evidence of their impact on quality? Conditions. To what extent are the current financing scheme, databases and other tools (guidelines, quality indicators) appropriate to implement P4Q in the Belgian health care setting? What are the most important facilitating and hindering factors? 7.1.2 Methods 7.1.3 Results The output of the systematic review on P4Q (see chapter 3 and 4) nor an additional search strategy using Dutch and French entry terms within the predefined search string identified any Belgian study. These limitations highlighted the need to collect the information as broadly as possible on a local scale by direct contact of all stakeholders involved. Because interviews of forty persons were planned as part of the chapter 8 data collection, these meetings were used as an opportunity to seek additional information on existing (P4)Q initiatives. They were asked to refer the research team to other persons involved in (P4)Q initiatives to provide additional information. These persons were contacted by phone and email, using a standardized template to collect (P4)Q initiative data. Numerous initiatives, programmes and applications were mentioned by the stakeholders and additional contact persons. However, the main bulk of information did not concern programmes which complied with the study P4Q definition. A number of programmes did involve a kind of financial incentive. But this incentive wasn’t in any programme directly related to the measured performance of participants with regard to predefined quality targets. In this section we provide however an overview of Belgian quality initiatives that were mentioned by the experts. These programmes provide possibilities to develop pay for quality initiatives, as will be further analyzed in section 7.2. A total of 14 programmes are described below. These most often mentioned programmes are: Primary + hospital care 1. Care itineraries (“trajets de soins”, “zorgtrajecten”) 2. Clinical pathways 3. Providers’ accreditation
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