Pay for Quality
Pay for Quality
Pay for Quality
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KCE Reports 118 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> 141<br />
8.1.1.2 The Belgian health insurance system<br />
A major obstacle in the achievement of quality of care, mentioned by multiple<br />
stakeholders is that the Belgian healthcare system is primarily focused on fee <strong>for</strong><br />
service, and is not explicitly related to the quality of the services provided. As a<br />
consequence we do not have a solid tradition in quality measurement nor do we have a<br />
yardstick to define the concept of quality/per<strong>for</strong>mance. Most stakeholders agree that<br />
changes are necessary in the future. Budgetary context will <strong>for</strong>ce us towards an<br />
increased level of accountability of all the players in the system and widespread<br />
implementation strategies <strong>for</strong> quality including e.g. benchmarking. Another future driver<br />
towards quality is considered the ageing of the population and chronic diseases in<br />
particular.<br />
The Belgian system is centrally driven, based on public insurers companies, our so called<br />
“mutualities”. In this context a big divergence could be noted as to the roles of private<br />
and public insurers in the definition and execution of pay <strong>for</strong> quality programmes. Some<br />
stakeholders argue that private insurers shouldn’t be associated to pay <strong>for</strong> quality<br />
programmes since there is a danger of ‘risk selection’ and what is called “managed<br />
care”. Other stakeholders however want to open the debate on the role of private<br />
insurers in our health care system. There is strong agreement that it is of no use to<br />
simply copying existing pay <strong>for</strong> quality initiatives from other countries since all health<br />
care systems are different.<br />
8.1.1.3 Type of payment system: FFS, capitation, structural or salary<br />
It is clear <strong>for</strong> all that, if pay <strong>for</strong> quality programmes would be installed in the future, an<br />
adequate financing system should be put in place, which should be more divers than the<br />
present system. Most stakeholders consider the fee-<strong>for</strong>-service system to be a strong<br />
incentive <strong>for</strong> action and service, as it ensures “availability” but not necessary<br />
“compliance to guidelines”. <strong>Pay</strong> <strong>for</strong> quality is seen as an opportunity to enlarge the<br />
diversity of paying systems by combining different systems into one programme.<br />
Capitation elements can mainly help primary care practices to act on practice<br />
populations rather than on individual complaints of patients. Structural financing <strong>for</strong> e.g.<br />
quality management and data monitoring is considered an important impetus <strong>for</strong> the<br />
implementation of pay <strong>for</strong> quality.<br />
Stakeholders see it as important that <strong>for</strong> every payment system a good analysis is<br />
required on what incentive types or quantities are desired and what are the potential<br />
negative consequences. If all the a<strong>for</strong>ementioned elements become part of a transparent<br />
plan, many stakeholders are willing to accept budget shifts within the present budgets,<br />
shifting profits and economies in one area to support other areas of the health care<br />
system. Most suggest that new financing mechanisms will be needed <strong>for</strong> new pay <strong>for</strong><br />
quality initiatives, especially <strong>for</strong> local and regional practice organisation and capacity<br />
building.<br />
8.1.1.4 Competition between different subsystems, different levels of care and different<br />
providers.<br />
Important elements with regard to competition between different regions, levels of care<br />
and providers were put <strong>for</strong>ward by multiple stakeholders. First, several stakeholders<br />
pointed out that the cultural differences in the way health care in general, and more<br />
specific quality issues are conceptualized and organised strongly differs between the<br />
Flemish and Walloon region of Belgium. From a legal perspective, ‘quality’ is the<br />
responsibility of the regions (Flanders and Wallonia), but since the federal government<br />
focuses on per<strong>for</strong>mance as well, the line between what is quality and what is<br />
per<strong>for</strong>mance is sometimes difficult to draw.<br />
Second, the competition between secondary and primary care still exists, and many<br />
stakeholders stress that quality should be transmural, with strong emphasis on the<br />
integration of both levels when implemented. In this context it is important that the<br />
differences between hospital and primary care are recognized. Hospital care is<br />
considered to be disease-oriented, whereas primary care targets integration,<br />
interpersonal relation and individual in<strong>for</strong>mation.