Pay for Quality
Pay for Quality
Pay for Quality
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140 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> KCE Reports 118<br />
Some stakeholders insist that quality improvement initiatives should stay or become<br />
part of the basic mandatory health care insurance, to avoid selectivity and inequality. It<br />
is considered an unacceptable option if quality would be limited to the additional or<br />
private insurance sector.<br />
8.1.1 Health care system characteristics<br />
All stakeholders consider key principles of our Belgian system to be individual freedom<br />
<strong>for</strong> patients and providers and a strong dedication in all actors to deliver high quality of<br />
care. It has been pointed out during the interviews that there is probably too much<br />
(therapeutic) freedom in our healthcare system and that pay <strong>for</strong> quality might serve as a<br />
solution to better deal with quality in general, and with the negative consequences of<br />
(therapeutic) freedom in particular.<br />
Another important characteristic of our health care system is that the payment system<br />
which is currently in place, -mainly based on fee <strong>for</strong> service-, implicitly assumes that<br />
quality will be delivered at all time and in all places. There are however very few clearcut<br />
quality criteria available that are related to (different levels of) payment (see the 14<br />
examples of quality related initiatives, in chapter 7).<br />
The Belgian healthcare system is also criticized because of its disease-oriented<br />
approach, which favours a specialist and hospital focus, its priority <strong>for</strong> cure over care<br />
and even more over prevention, with little emphasis on primary care. For this reason<br />
the relation between primary and secondary care is considered as imbalanced, which<br />
could be an important barrier towards a movement of integrated care and the<br />
development of a more public health related approach.<br />
Another shortcoming of our system, as perceived by a substantial number of<br />
stakeholders, is that there is a lack in the transparency of the decision making process at<br />
all levels, with no open communication. As quality gradually becomes a topic that moves<br />
and concerns many stakeholders, quality issues should be clearly brought on the public<br />
agenda.<br />
Most stakeholders conclude that the current level of care is “suboptimal” leaving<br />
substantial room <strong>for</strong> improvement. But be<strong>for</strong>e any system of pay <strong>for</strong> quality can be<br />
installed, some stakeholders consider it important to first define what is meant by<br />
quality (within the Belgian context), its dimensions, its critical success factors and how it<br />
should be measured and promoted. This could prevent resistance to pay <strong>for</strong> quality<br />
initiatives in the long run.<br />
8.1.1.1 Values of the system<br />
Key values of the Belgian healthcare system, as put <strong>for</strong>ward by a few stakeholders, were<br />
“accountability” and “professional autonomy”. These elements were seen as two sides<br />
of the same coin, in the sense that more accountability would potentially lead to less<br />
autonomy, and vice versa. In this context improved “transparency” is seen as a value<br />
that could facilitate the acceptance of greater levels of accountability in our healthcare<br />
system.<br />
All stakeholders that mentioned the value “accessibility” considered it as a crucial value<br />
<strong>for</strong> our health care system as a whole, and when considering the implementation of pay<br />
<strong>for</strong> quality.<br />
Less agreement was noted between the stakeholders <strong>for</strong> what concerns the value of<br />
“privacy” and “confidentially” of data and medical in<strong>for</strong>mation. Some stakeholders fear<br />
that less privacy would lead to less professional autonomy. Appropriateness of care also<br />
seemed to be an important value to some stakeholders. <strong>Pay</strong> <strong>for</strong> quality should there<strong>for</strong>e<br />
focus on both appropriate care at the right cost, whilst considering the short-term and<br />
long-term outcomes.