Pay for Quality

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.