Pay for Quality

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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.
KCE Reports 118 Pay for Quality 127 It’s like different pieces that are not brought together in a full quality improving puzzle. This lack of quality improvement tuning also leads to cost effectiveness questions concerning budget allocation. Why is and remains a large proportion of quality supporting resources reserved for an incentivized provider accreditation system, while other programmes, often with a higher EB supported effect size, are supported with lower resources? A general P4Q philosophy implies that payment becomes a tool directed at those priority areas and initiatives yielding the highest results in health gain. This requires however that the resources consumed through historical merits (such as provider accreditation) may be reallocated based on evidence and stakeholder consensus. This implies not a reallocation in terms of who receives financial resources and their amount, but a reallocation in terms of the criterion used, the basis of distribution. It can be confirmed that none of the described programmes currently fit the definition of P4Q, which is based on the actual measurement of quality and the linkage of those measurement results to the allocation of a financial incentive. This section has provided a general overview of what is available in Belgium to support components of a quality circle. However, these components need to be specifically related to the revised P4Q framework to thoroughly analyze programme designs as compared to P4Q recommendations, and the feasibility of modification. This subsequent step is described in the following section. 7.2 FEASIBILITY STUDY OF IMPLEMENTATION OF P4Q IN BELGIUM 7.2.1 Introduction When addressing the feasibility of P4Q within a Belgian context there are two main questions to be answered, building further on the theoretical and empirical guidance presented before: Can P4Q be implemented in Belgium building further on existing quality improvement initiatives to design, implement and evaluate P4Q framework components? Can P4Q be implemented in Belgium starting from scratch, i.e. designing, implementing and evaluating all P4Q framework components independently of existing Belgian quality improvement initiatives? Next to feasibility, this chapter will explore the advantages and disadvantages of both options. 7.2.2 Methods 7.2.3 Results This chapter makes use of the empirically revised conceptual framework (Chapter 5) to analyze strengths and weaknesses in current quality circle components to define P4Q threats and opportunities. The level of correspondence for both the quality initiative independent approach and the quality initiative dependent approach with the set of ‘to do’s’ is used as the central parameter. The feasibility of modifications is assessed. Appendix 12 provides an overview table of both options as placed within the P4Q framework. 7.2.3.1 Starting from existing quality improvement initiatives Quality dimensions A strength and P4Q opportunity is the fact that twelve of the fourteen initiatives do not address efficiency exclusively. Only two initiatives (capitation revaluation of primary health care centres and reference payments of hospitals) are only focused on cost containment within the efficiency domain of quality. Since P4Q looks beyond efficiency only, these two initiatives are difficult to relate. It is remarkable that such efficiency focused initiatives show some distinct characteristics as compared to the others: They rely on mandatory participation.
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