Pay for Quality

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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.
KCE Reports 118 Pay for Quality 129 Quality targets One initiative, providers’ accreditation, does not define specific quality targets measured. It therefore cannot be used together with P4Q in its current form. Many initiatives (breast cancer screening, capitation funding revaluation in primary health care centres, reference payments for hospitals, prescription feedback, the global medical record and its future preventive module) only make use of process targets. Two initiatives combine structural and process targets (hospital accreditation, use of the EPA tool). Although useful for P4Q purposes, the current state of the art includes at least (also) intermediary outcome measures. Care itineraries (process + intermediary outcome), clinical pathways (process + outcome), hospital benchmarking (process + outcome), centres of reference (structure + process + outcome) and the quality and patient safety in hospitals initiative (all target types possible) fit best as P4Q opportunity. As already noted above, the current level of local adaptability should be further considered. When a local organization implements P4Q independently, it is free to design the quality target and measurement system according to internal needs. However, when P4Q is implemented nationally or regionally, the introduction of a financial incentive should be linked to a set of minimal requirements to ensure that the P4Q system conforms to best practice standards. These standards provide the highest probability of reaching the national/regional priority goals and targets. Too much freedom in target selection induces a risk of free rider behaviour. This means that participants might select targets based on the level of ease to reach them. Thus they focus on receiving financial resources without true quality improvement or maintenance. This would reduce P4Q’s health gain potential and be unfair in terms of incentive allocation. The design of standards to reduce this risk can be the responsibility of professional scientific organizations, which represent different medical disciplines. The number of target indicators available and/or used in the different quality improvement initiatives gives enough input to design a P4Q target set which is not too limited, nor too complex (see for example indicators within the EPA tool and within hospital benchmarking). The exact number should be specified based on all stakeholders’ consensus. Breast cancer screening, being a true P4Q initiative, is based on only one target measure, which is quite narrow in approach. Next to the two efficiency focused initiatives (reference payment for hospitals, capitation revaluation in primary health care centres), and prescription feedback which all address inappropriate care (overuse) exclusively, there are five initiatives with an exclusive appropriate care focus (underuse): care itineraries, breast cancer screening, centres of reference, the global medical record and its planned preventive module in primary care. P4Q requires at least the appropriateness approach, preferably in combination with attention for inappropriate care. This combination can be found in the other six initiatives, although again sometimes dependent on local decisions. Concerning target selection and definition criteria a SMART configuration is present in most initiatives, except for the reference payment of hospitals, the capitation revaluation, and providers’ accreditation. One of the main weaknesses in most initiatives is the lack of evidence base requirements. Exceptions are the care itineraries, breast cancer screening and the preventive module in the global medical record. These more recent initiatives put the evidence base central to target selection. Most other initiatives (clinical pathways, quality and patient safety in hospitals, EPA tool, hospital benchmarking, etc.) provide an opportunity to participants to make use of EB standards, but participants remain completely free to make use of EB or not. An EB precondition should be reinforced for a P4Q opportunity to succeed. The same kind of noncommittal approach can be found in terms of room for improvement as a target selection criterion. Many initiatives advise and teach participants to base target selection on existing quality gaps, but in the end the selection is often locally decided upon without any level of supervisory monitoring of compliance with baseline needs.
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37. HTA Magnetische Resonantie Beel
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