Pay for Quality

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142 Pay for Quality KCE Reports 118 Third, as competition is still present between individual caregivers in their practices, and the different hospital services, it is important that pay for quality programmes do not increase the level of competition between individual caregivers. 8.1.1.5 Availability of information systems Availability of good and performing information systems is considered a critical success factor by several stakeholders for the successful implementation of pay for performance programmes. In Belgium we have a substantial amount of (socio-economic) data. There is however an apparent lack of integration of relevant data as is needed to measure performance, rewarding, and for the detection of duplications and overlap in care delivery. Nowadays, the available data are used for ‘ad hoc’ budgetary decisions and control, but not for epidemiology utility. As a consequence, very few quality indicators are derived from Belgian data sources and are used in quality measurement, with the exception of e.g. hospitals that regularly receive feed-back derived from centralised databases. The use of valid indicators is a particular problem in primary care that however has the potential to provide important epidemiological data. Support for computerization and data coding systems within the electronic medical record is felt as urgently needed. Several stakeholders state that there are at present already enough good and interesting data available for public reporting. They considered public reporting already as a good step towards sensitization on quality and quality related issues. In this context, the notion of “guided transparency” was mentioned by one stakeholder, i.e. the public should be helped to read and understand the meaning of the different data. In conclusion: all stakeholders agree that information systems play an important role to facilitate communication between individual caregivers and different levels of the healthcare system, the organisation of feed-back recall systems. 8.1.2 Payer characteristics Three essential elements were put forward by the stakeholders that mentioned this point with regard to the vision of the payer. These were a) the potential for bias in the view of the payer, and more in particular b) the discrepancy between payers and providers in their views on pay for quality programmes, and c) the potential impact of pay for quality programmes on the repartition of the budget. Regarding a), a number of stakeholders have pointed out that insurers (payers) might be biased in their views on pay for quality programmes, since they primarily defend the interests of their members. As a consequence, the cost of pay for quality programmes might be considered the primary focus of the payer. Regarding c, an important advantage of pay for quality programmes that was noted for the payer’s perspective was that these programmes will probably contribute to a better repartition of the budget. 8.1.3 Provider characteristics 8.1.3.1 Awareness, perception, familiarity, agreement, self-efficacy Stakeholders stress the importance of recognizing existing and future ‘attitudes’ in providers. To give an example, satisfaction in care providers will probably increase if the latter believe they contribute to the quality of care by adhering to evidence based practices. Pay for quality is in this context considered as a means to add value to the (medical) profession, as it induces a reflective attitude of medical doctors on their own practice, which in itself will induce quality. One stakeholder clearly said that participation at pay for quality programme will automatically lead to changes in attitude. Particularly stakeholders from unions stress that if pay for quality programmes are perceived as assessment, control and interference in their practice, it will automatically lead to important resistance (to change), and thus resistance to the programmes themselves.
KCE Reports 118 Pay for Quality 143 The use and reliability of the proposed quality measurement tools must be clearly understood and positively judged by the providers in order a programme to become successful. Communication, transparency again will be very important. 8.1.3.2 Medical leadership, role of peers, role of industry A substantial number of stakeholders consider medical leadership as a critical success factor for pay for performance programmes. Medical leadership consists of the definition of good clinical practices and aspects of high quality care and requires the presence of persons that are recognized by their peers as true medical experts. Medical leadership is considered by the stakeholders as a shared responsibility between both medical doctors (specialist and general practitioners), but also universities, hospitals as well as the pharmaceutical industry. The process of peer review and feedback is considered essential to create consensus and trust between the actors involved. A particular role is attributed to GLEMS/LOKS, as well as to local general practitioners groups (‘cercles’, ‘kringen’), as forums where medical leadership is to be developed, and in particular where results of pay for quality programmes should be discussed. 8.1.3.3 Existence / implementation of guidelines, room for improvement The use of guidelines is subscribed as an important element in the implementation of pay for quality programmes. Some stakeholders, not only from the providers’ bench, consider guidelines as an important tool, but point out that guidelines are benchmarks, give clear indication when the provided quality is good, but can not be mandatory. Critical remarks on clinical guidelines were that they are often unrealistic concerning the targets set and often are poorly adjusted to real life situations in primary care. Primary care not only has to adopt these guidelines, but often has to adapt them. Pay for quality programmes, as they often are transmural, regional and include specialist and general practitioners, can potentially contribute to this mutual adoption process, and diminish the diversity of existing guidelines, leading to better agreement and acceptation. 8.1.3.4 Level of own control on changes A recurrent remark made by several stakeholders is that pay for quality programmes might be perceived as taking control out of the hands of the individual providers. Moreover, pay for quality might be perceived as a system that induces punishments in different ways. Stakeholders indicate that medical specialists might possibly be more resistant to pay for quality compared to primary care physicians. It therefore is considered of high importance that providers become more effectively stimulated to define their own standards of quality of care and take an increased responsibility to define, choose en disseminate their clinical guidelines. It is recommended that the existing feedback which until now has been a merely financial feedback changes to what is called “multidimensional self–assessment”, starting from clinical data. Especially the providers’ representatives pointed out that providers do not have complete control on the patients’ contributions in the achievement of quality. They fear that this could lead to undue penalty. There is no way to oblige the patient to follow a treatment or undertake some technical examinations. It makes the evolution of a disease rather independent from the providers’ care. Again providers’ representatives fear that official bodies will use transmitted data to control their practices. They have more confidence in their own scientific institutions. 8.1.4 Patient characteristics The role of the patient, and more in particular compliance of patients to the medical regimen was considered highly important by most stakeholders when discussing clinical outcomes of care. One stakeholder stated that pay for quality programmes will have a low impact on patients, despite their potential influence on outcomes of care.
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