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