Pay for Quality

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132 Pay for Quality KCE Reports 118 P4Q incentive A number of quality initiatives are not directly related to financing (clinical pathways, hospital accreditation, EPA tool, centres of reference, hospital benchmarking). Financial resources are not specifically related, except in terms of implicit internal costs (e.g. number of FTE’s involved, payment of participation fee) and implicit revenue effects (e.g. patient volume effects due to public recognition or implicit rewarding of a shorter hospital LOS as part of the current financing system). These initiatives are not explicitly incentivized financially. An incentive and its structure would have to be implemented starting from scratch. Other initiatives are explicitly incentivized, but not directly related to quality performance (care itineraries, quality and patient safety in hospitals). We also include capitation revaluation, providers’ accreditation, reference payments of hospitals, prescription feedback, the global medical record and its preventive module in this category. Most of these initiatives are financed based on a fixed fee independent of cost or quality (surpassing efficiency and/or volume performance). Some are however measuring and/or reporting related as a performance criterion (care itineraries, quality and patient safety in hospitals). This can be considered a first stage in a phased approach of incentivizing quality of care. One initiative, breast cancer screening, includes an explicit financial incentive directly related to quality performance. Incentive structure The not per se strict P4Q incentives that are used in current initiatives show a number of strengths in terms of incentive structure best practice. The first is the predominantly rewarding nature. The second is the absolute methods use (participants are rewarded independently from each other based on an objective, known and fixed criterion to be pursued and based on each participant’s own merits). Also in terms of stability and simplicity vs. complexity there are promising signs based on existing initiative characteristics. The frequency, which is often yearly, provides sufficient time for practice change and for practical data collection modalities to be feasible. However, in long term a focus on shorter time intervals, with assistance of automatic data collection methods, may prove worthwhile to ensure a sense of urgency and to heighten awareness. What is often lacking in current quality initiatives is the size of the incentive (well below 10% of total revenues). In addition, the incentivized level is often, as recommended, the individual provider in primary care (e.g. prescription feedback, preventive module). There is no incentive focus on the team level in primary care, except through the complementary goals within the care itineraries initiative, and through the team allocation level within the capitation revaluation initiative. In hospital care the incentive is in existing initiatives awarded to a hospital as a whole (quality and patient safety in hospitals, reference payments of hospitals). There is a lack of incentive focus towards individual providers and teams of providers improving quality within hospitals. This serves as a further point of attention with regard to P4Q.
KCE Reports 118 Pay for Quality 133 Figure 12 : P4Q concepts: Incentives Incentives Strength Weakness Some pay for reporting initiatives Incentive structure: Predominant use of rewards Predominant use of absolute incentive methods Attention for incentive stability Focus on simplicity of the incentive structure Lack of explicit financial incentives in some initiatives Lack of a relationship with quality performance in some initiatives Small incentive size (
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