Pay for Quality

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134 Pay for Quality KCE Reports 118 Figure 13: P4Q concepts: Implementation, communication and evaluation of the programme Implementing and communicating the programme Strength Weakness Attention for involvement of providers in setting goals in most initiatives High level of communication in most initiatives Use of voluntary participation in most initiatives Some good examples of using a staged approach Use of an embedded quality support approach in most initiatives 7.2.3.2 Starting from scratch Evaluation of the programme Strength Weakness Often premature to assess due to pre evaluation stage or ongoing first time evaluation Some initiatives make regular use of evaluation (Strength), others sporadic or exceptional The ‘starting from scratch’ option gives complete freedom to focus on quality dimensions and quality targets which fit best. During a first phase ‘effectiveness’ can be the main target dimension, with monitoring of other dimensions to prevent unintended consequences (e.g. level of equity, provider experience and cost effectiveness). Later on other quality dimensions can be included (e.g. care continuity and coordination). P4Q can be of similar value, both for primary care as for hospital care. Based on evidence there is no argument to prefer one of both. P4Q can support quality throughout different settings, with operational modifications wherever necessary. However, according to the WHO primary care should receive a particular focus since it can have a stronger impact on health if guidelines are more widely spread and applied, and prevention and health promotion are correctly managed. 262 Rewarding quality goals in general practice can contribute to strengthen primary care, leading to a more balanced health care system. There is also no reason to focus on preventive, acute or chronic care separately. A mix of targets can be included to emphasize and incentivize the complementary value of an integrated approach. The quality targets within a Belgian context can consist of a combination of structural, process and intermediate outcome measures. Long term outcome effects are practically assessed by relating them to short term intermediate outcome effects. The different types of indicators are already widely available within Belgian healthcare. Existing knowledge, experience and evidence can therefore guide the target selection and definition process.
KCE Reports 118 Pay for Quality 135 The number of targets can be phased in, but to gain sufficient awareness and behavioural effect from the start a too low number (e.g. below five) should be avoided. One can choose between an immediate appropriateness (tackling current underuse) and inappropriateness (tackling current overuse) approach or also using a phased approach in this respect. In the end both underuse and overuse targets should complement each other in a logical manner. Since Belgium has experience in both, this poses no specific problem. However, it might require that the separate worlds of cost containment and quality improvement come closer together based on supportive evidence. Within this approach at least the following target selection criteria would be used: the presence of a high level of evidence, SMART configurability, and sufficient room for improvement based on local baseline measurement and indications of target specific cost effectiveness (health gain per unit of expense). Finally, it is important to systemize a continuous dynamical approach of quality improvement. Existing Belgian PDCA based initiatives are a source of input herein. The biggest operational obstacle of P4Q implementation in Belgium (as elsewhere) is the set of conditions of quality measurement once the targets have been defined. P4Q from scratch can be based on already collected data and/or additionally collected data. Already numerous databases are compiled within Belgian healthcare, some for quality purposes, and others for financial or administrative purposes. Therefore, when possible, available data can be used (combined with a thorough validation process). However, data availability should not replace the target selection criteria as presented above. In short term it may be necessary to collect a limited amount of additional data. The bureaucratic workload may be minimized by the use of a random sampling approach of a provider’s health care records. As exemplified abroad, automation of data collection is perfectly feasible when nationally supported (as also in Belgium is already largely the case for financial and administrative data). Primary care should be a particular target, since the current quality of data registration at the practice level is currently very low. Recent national initiatives to standardize and integrate health care record IT support are a first step towards automation. There is a well founded Belgian tradition of risk adjustment of outcome measures, for example in hospital care based on case mix grouping. A similar approach can be used for primary care, based on basic information about patient and provider characteristics. Although in Belgian initiatives often exclusion criteria are applied to calculate target performance, exception reporting as defined abroad (e.g. in the UK) is in Belgium not used. One exception is the use of variance tracking and analysis as part of care pathway initiatives. Deviations of what is considered expected care are specifically and systematically reported in some of these projects. The difference with the UK approach is the level of standardization of exception (or deviation) arguments. Whereas in the UK only a few predefined arguments are accepted to apply exception reporting, in the Belgian care pathway approach arguments are not predefined. They are however registered and used as an additional input for quality improvement. The care pathway example illustrates the feasibility of exception reporting in Belgium when a stakeholder consensus on the appropriate methods has been reached. Belgian quality improvement initiatives in general show a lack of monitoring for unintended consequences with regard to care equity for patients, financial equity for providers and equity in terms of attention to the whole of quality priorities. For the first two types no additional data collection is needed; only a specific comparative attention when analyzing target performance. To safeguard equal treatment of different priorities, data on not incentivized targets should be available. These can often be extracted from already existing databases, e.g. from current benchmarking initiatives. This remains a necessary condition of the starting from scratch option. The P4Q financial incentive could be combined with existing financial mechanisms and with the even more important non financial incentives which drive provider behaviour. An explicit positive financial reward can be attached to performance, with a minimal size of 10% of provider income. This is gradually staged, based on planned budget increases, to guard national budget equilibrium and predicted growth. Initially cost coverage of quality improvement effort is considered the minimum.
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