Pay for Quality

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