Pay for Quality

128 Pay for Quality KCE Reports 118
Both use a relative incentive in which allocation is dependent on the performance of
others. None of the target selection criteria are used in these initiatives (e.g. level of
evidence). Both focus exclusively on process measures (medical imaging, clinical biology,
etc.) and financial outcomes. Both are static in terms of goal specification and make use
of secondary data analysis based on administrative data. Whereas the capitation
initiative includes a financial reward, the reference payment initiative is based on a
negative financial incentive. This drives it further from P4Q recommendations.
Characteristics like the mandatory nature, and the relative incentive allocation are
mostly absent in the other twelve initiatives more focused on other quality domains.
The rationale for this difference is at present unknown.
A P4Q programme should, as a first priority, be focused on clinical effectiveness.
Furthermore, if other domains are also addressed, the P4Q opportunity is reinforced.
One initiative, providers’ accreditation, has no very clear quality domain focus.
However, one can assume that continuing education as one of the intervention items
supports effectiveness, cost-effectiveness and coordination of care.
The global medical record initiative in primary care is primarily focused on continuity
and coordination of care. This makes it a less good candidate to fit with P4Q in its initial
stage, unless additional payments are introduced as an incentive to reach specific
targets, as is the case with the preventive module (initiative IX).
The other ten initiatives all focus upon clinical effectiveness in combination with one or
more other domains. This supports the P4Q opportunity. However, some of these
initiatives give participants more leverage to prioritize quality domains locally. Examples
are clinical pathways and the quality and patient safety in hospitals initiative. When such
initiatives are incentivized financially, the balance between national, regional and local
quality domain priorities deserves specific attention. Based on different points of view
(standardized minimal EB approach vs. local adaptable approach) this can be seen as an
additional opportunity or threat to P4Q implementation.
Target population
Both in primary care as in hospital care there are sufficient quality improvement
initiatives as a P4Q opportunity. Some (provider accreditation, care itineraries, clinical
pathways) focus on the two settings. This might reinforce patient centeredness
throughout a patient’s trajectory, and support coordination, continuity and
communication to minimize gaps of care. However, implementing P4Q in these settings
simultaneously will likely also be a greater challenge. Therefore both a cautious as a
more ambitious approach can be followed. Stakeholder consensus can assist in making
the appropriate (stepwise) selection.
The different types of care (preventive, acute, chronic) are all addressed in initiatives to
support P4Q implementation. Until recently preventive care received lesser attention in
initiatives. However, the currently being developed preventive module in the global
medical record for primary care will fill this gap, next to the breast cancer screening
initiative.
As described in previous chapters, P4Q can support both medical condition specific as
generic quality improvement initiatives. Initiatives like care itineraries, clinical pathways,
reference payments for hospitals, breast cancer screening and the preventive module in
the global medical record are mostly medical condition specific. Capitation funding
revaluation in primary health care centres, providers’ accreditation, use of the EPA tool
and the global medical record are generic in terms of target population. Finally, the
quality and patient safety in hospitals initiative, hospital accreditation, hospital
benchmarking, centres of reference, and prescription feedback show medical condition
specific and generic components.