Pay for Quality

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136 Pay for Quality KCE Reports 118 This staging can coincide with a phasing of pay for participation (measuring) towards reporting, and finally, performance. Pay for reporting is in some Belgian quality improvement initiatives already the case. The P4Q incentive is allocated partly to individual providers and partly to providers as a local team, using for example absolute performance criteria. This means that each person’s/team’s level of performance is incentivized independently, without competition based on mutual performance comparison. Furthermore, the incentive is partly linked to reaching predefined thresholds of performance for each indicator and partly linked to the size of improvement through time. Initially, each target has an equal weight in incentive allocation. Afterwards adjustments can be made for target specific workload and expected health gain. It is necessary to gather pilot data to devise this weighting structure. Composite measures and an ‘all-ornone’ approach aren’t used during the initial years of P4Q implementation. These options require a higher level of P4Q experience and additional research. The incentive is closely linked to feedback of performance and provided two or three times a year. The incentive structure remains stabile. Targets are regularly revised based on local room for improvement. The above described incentive structure reflects the level of complexity of the incentive programme. This seems transparent enough to fit with provider understanding and awareness. In long term the incentive structure may become more complex, requiring specific attention for front office programme communication. All stakeholders (state, payers, providers, patients and scientific community) are involved during the P4Q design and implementation process. Together they determine through national or regional representation the balance between programme uniformity (e.g. evidence based requirements) and local adaptability (target selection). Professional groups and medical scientific societies have a key role in setting performance standards. In the end all professional providers can decide democratically on the adoption of the programme or not. After programme design a direct and intensive communication towards individual providers is set up, as part of a broad information platform. Participation in the programme by providers is voluntary. Modelling and pilot testing precedes a wide dissemination of programme implementation. The programme is embedded into a wider quality improvement support frame. Tools and education are provided to improve and/or maintain performance. Existing quality initiatives can be used to compile such an integrated support platform. With regard to programme evaluation, target performance is monitored during a sufficiently long time interval, and regularly resampled afterwards. The same is true for a limited selection of not incentivized key targets. The programme as a whole is evaluated using at least a quasi experimental study design, with concurrent and before after comparison points. The support of the use of (cluster) randomization is determined based on a consensus of involved stakeholders. As exemplified abroad, conducting a P4Q RCT, as the best means to minimize selection bias, is a feasible approach. A two phased trial, in which the control group also receives the P4Q intervention during the second phase, supports recruitment of participants in both groups. Because a team (a GP practice and/or a within hospital team) is part of the P4Q focus, cluster randomization should be used. The alternative of randomization is the use of an observational design such as a cohort study or an interrupted time series. However, a cohort study does not take selection bias into account with regard to unknown confounder variables. The use of an interrupted time series requires a long term study approach with a sufficient number of measurement points. This design supports rather long term monitoring than the assessment of the effects of implementation before dissemination. The P4Q programme is optimized based on the evaluation results.
KCE Reports 118 Pay for Quality 137 7.3 DISCUSSION AND CONCLUSIONS This chapter addresses the question of feasibility of P4Q within the context of Belgian healthcare. The components of the conceptual framework were used to study feasibility starting from existing quality improvement initiatives and/or starting from scratch. The option to start from scratch has the advantage of lacking any historically determined restraints which result from an already ongoing quality initiative. Each existing initiative has its own quality definition, goals, targets and quality measurement system in place. Some combine this already with financial incentives, others don’t. Therefore, when adding P4Q to these initiatives this might threaten the original programme purpose when done inadequately. In addition, the existing common practice might in itself become an obstacle to state-of-the-art P4Q implementation. This risk of combining both and coming out with none of both adequately accomplished should be carefully considered. A disruption of an ongoing initiative might undo years of effort and evolution. However, these risks neither imply that an existing quality initiative never might evolve towards P4Q integration. As initiatives are regularly evaluated and modified, each initiative might add P4Q characteristics, based on the internally based consensus of long term involved stakeholders. This process describes a kind of natural evolution of existing initiatives towards P4Q. As described in the results section, it is feasible to adapt existing quality initiatives to include a P4Q component. Although there are some weaknesses (e.g. lack of monitoring of unintended consequences), there are also many strengths (e.g. high experience in implementing and communicating a programme) to support P4Q implementation. The identified weaknesses and threats can be addressed specifically, based on national and international theory, evidence and stakeholder consensus. The analysis of existing initiatives has shown that there is a substantial body of knowledge and experience that can be leveraged to assist in P4Q implementation. It is not about ‘reinventing the wheel’. The option to start from scratch therefore shouldn’t result in ignoring all lessons learned, on the contrary. Furthermore, the existing quality initiatives can also be used as a target, because most of them are examples of care management processes. P4Q can be aimed at the use of benchmarking, the use of clinical pathways, the use of safety management tools, etc. Practical feasibility has been confirmed in this chapter. Many of the so called weaknesses are more related to the will to address them as to the ability to address them. The level of data validity is one example often cited as a potential threat to P4Q implementation, due to other purposes of existing data collection and due to the risk of gaming. This argument serves as a primary example of what P4Q in fact stands for: taking quality of care seriously and acting accordingly, based on verifiable quality demanding standards. Just as financial data are strictly monitored using an elaborate accounting system, quality data deserve a similar ardour. There is no room to apply double standards when addressing quality of care as compared to financing of care. P4Q relates both and reformulates priorities. The idea of ‘for financing purposes’ becomes equal to ‘for quality purposes’. Instead of a permissive approach towards gaming, and using this as an argument against P4Q feasibility, P4Q enforces high standard requirements, and the reallocation of resources and effort to ensure those standards. Currently it is considered common sense in every sector that gaming with financial data equals fraud and that a control system is institutionalized. The same kind of high intensity attention, effort and resources are consumed daily to ensure that one’s PC receives regular updates to maintain adequate functioning. This same kind of logic (enforcing minimal standards of how to address quality, monitoring those standards, and updating those standards on a very short time span) is not applied on quality of care, the core value and mission of healthcare. As such these are questions of ‘willingness’ and not of ‘ability’.
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