Pay for Quality

126 Pay for Quality KCE Reports 118
Table 20: Reference payment hospitals
XIV. REFERENCE PAYMENT –HOSPITALS-
Initiated by RIZIV/INAMI
Overall objective To reduce the level of overuse of specific care interventions
Date of implementation in Belgium Start of development in September 2002, revised during
2002-2008. Latest version implemented in December 2008
(applicable for hospital admissions since 2006).
Target audience Medical care in acute and chronic general hospitals, with an
exclusion of one day stays. Twenty surgical and 12 medical
commonly present DRGs are included for SOI 1 and 2 (low
severity of illness patient admissions). This equals 18% of all
hospital admissions.
Content Comparison of hospital expenses for medical imaging, clinical
biology and technical services with the national median per
diagnostic group (APR-DRG) and SOI level + 10% k . Since
2009 the time frame of included services can be broadened
to include the identified services during 30 days before
admission to prevent cost shifting. High LOS outliers are
excluded from the national median calculation. Services with
existing standard expense payments are also excluded. Since
2009 hospitals are prospectively informed about the
Primary focus (structure, process,
outcome)
reference norms as to enable the prevention of excesses.
The targeted expenses are related to the processes of
medical imaging, clinical biology and technical services,
although not specifically measured in non financial terms.
Type of indicators used (if any) Financial data/outcome. No structure, process or clinical
outcome measures.
Purpose of indicators used To standardize expenses and reduce variability as justified by
the national average comparison.
Type of incentives When the total selected hospital expenses exceed the
reference norm, a hospital is obliged to refund the total sum
of exceeding (higher) differences above 1000 euro. There
are no incentives related to an expense position below the
reference norm. Since 2009 minimal thresholds can be
established to prevent overly pressure on the national
average.
Results (if available) No results evaluation available, with the exception of
periodic hospital feedback reports.
Sources (most relevant ones) See www.riziv.be and KCE report vol. 17 261
Total budget About 16.7% of total national expenses for the three types
of included services.
7.1.4 Discussion
Although there is a lack of peer reviewed publications on Belgian quality initiatives, a lot
of programmes support quality. Here we were only able to present fourteen of them,
but even these fourteen illustrate the wealth of initiative and effort to address quality,
and the diversity of approaches followed.
Evidence on programme effects is however often lacking. The different approaches are
very programme specific. Currently it is unclear how these initiatives all fit together in
their mutually shared mission of improving quality of care. There is no encompassing
national, regional or local quality improvement strategy directed at healthcare. Although
diversity leads to creativeness, experimentation and innovation, the lack of a common
platform (harmonization of priority setting, target selection, supporting tools, etc.)
induces a risk of creating quality gaps between initiatives and between decision making
levels.
k Each diagnostic group (APR-DRG) is subdivided into four categories of severity of illness (SOI), ranging
from 1= ‘low severity’ up to 4= ‘high severity’. The median expense at this sublevel is increased with ten
percent to calculate the threshold of reference payment.