Pay for Quality

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.