Pay for Quality

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’.