Pay for Quality

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144 Pay for Quality KCE Reports 118 8.2 PART II: IMPROVING QUALITY THROUGH P4Q 8.2.1 Quality and its dimensions, as seen by Belgian stakeholders Overall, stakeholders agree that quality has so far not received sufficient attention within our Belgian healthcare system and by policy makers in particular. Most stakeholders explicitly recognize the importance of quality and have often made reference to the gradual growth in the number of quality initiatives that are launched in both hospitals and primary care. Quality definitely needs to become a priority on the political agenda and this is considered a crucial starting point and even a “conditio sine qua non” for pay for quality programmes to reach their full potential. Many stakeholders consider quality as a multidimensional concept of which the different elements are interconnected. When making reference to quality dimensions, the most common cited dimensions were effectiveness, efficiency and safety of care. There is a consensus amongst the stakeholders that high quality management of health care consequently requires a multidimensional approach. 8.2.1.1 Safety of care As a crucial aspect of quality of care, patient safety was often referred to in relation to structural and process aspects of care. Pay for quality is considered by the stakeholders to potentially enhance (a culture of) fault reduction amongst providers. 8.2.1.2 Equity and access to care A wide consensus on the importance of equity as a dimension of quality was expressed. Some stakeholders state that, if quality of care has to be improved within the social context of an increasing gap between rich and poor, it must be for all patients, at an affordable cost, proportional to their income. In this context, pay for quality programmes should pay attention to the underuse of services in particular patient populations for which social criteria need to be applied to ensure access to care. Yet, although accessibility is a crucial aspect of high quality care, it was only mentioned by a few stakeholders, including insurers, hospital chief executive officers and members of regional/community governments. The latter stakeholders emphasized various dimensions of accessibility, i.e. proximity as well as cultural and financial barriers. Pay for quality programmes should not forget to focus on particular populations that are at risk of low access to services such as migrants and detainees. 8.2.1.3 Effectiveness Effectiveness of care is considered a basic property to the functioning of our health care system. Two important dimensions, as defined by Campbell et al. (2000), were addressed. These include effectiveness of clinical care and effectiveness of inter-personal care. The effectiveness of clinical care in Belgium was questioned in terms of both volume and outcomes (e.g. cancer treatment), and for this reason it was doubted that our system can be top-rated when comparing it to other systems. As quality is scarcely measured in Belgium, the aforementioned finding is partly based on private and international reports. The second dimension of effectiveness of care, interpersonal care, was most often cited by representatives of patient organizations, and primary and secondary care. In this context, the protection of the privileged patient-doctor relationship in general practice is still considered a core value. Some stakeholders therefore argue that revaluation of the intellectual act is important when speaking about pay for quality, and that it a crucial step towards the development of such programmes. Good claim management in hospitals was also cited as a concern in interpersonal care.
KCE Reports 118 Pay for Quality 145 8.2.1.4 Patient centeredness Patient centeredness was highlighted as a dimension of quality of care by mainly stakeholders representing providers, insurers and patients. Patient centeredness is a concept with a lot of different dimensions and operationalized in different ways by different providers. Some relate it to service to patients, positive communication with patients and taking individual responsibility for the patient. Several aspects of patient centeredness were put forward by the stakeholders including service to patients, open communication with patient, taking individual responsibility for the patient, management of the disease by the patients themselves and information management. For what concerns the latter, some stakeholders argue that patients should be informed on the involvement of providers in quality approaches, (particularly when hospitalized), referral to specialists or when informed consent is needed. The importance of privacy and confidentiality was also cited. Patient-centeredness was not presented by the stakeholders as an approach that starts and finishes with patients’ expectations and priorities. As opposed to this, the Belgian healthcare system is considered by some stakeholders as still having strong paternalistic reflexes where the provider and the system know what is good for the patient without asking him/her. 8.2.1.5 Cost-effectiveness, efficiency of care Most stakeholders recognized the importance of cost-effectiveness as a dimension of quality of care, but it was especially highlighted by Flemish stakeholders. 8.2.1.6 Continuity of services, coordination of care The dimensions continuity of services and coordination of care were recognized as important dimensions of quality of care. Especially continuous and integrated care were underlined by some stakeholders as an unattained objective in Belgium. Where the focus on integrated care is somewhat more explicit in primary care compared to other levels of the healthcare system, multidisciplinary coordination needs to be improved at all levels, and especially between hospital and primary care. Our current dominant payment system (fee for service) has led to fragmentation of care to a large extent. Pay for quality is therefore considered a valuable option to improve continuity of care and coordination of services since it allows for a variation in the sources of income in providers that might lead to a broadening of their look on diseases and related processes. 8.2.2 Patient populations and goals for quality projects 8.2.2.1 Defining goals A central remark made by several stakeholders is that objectives must be valuable to patients, providers, insurers and the government. Stakeholders highlight the need for a preliminary and global assessment of our current health care system first, rather than setting goals for delimitated problems. When defining goals for pay for performance programmes, stakeholders made reference to the global definition on health, as defined by the World Health Organization (WHO). The WHO defines health as ‘a state of optimal physical, social and mental well-being’. For this reason, both clinical care, health promotion/preventive care are aspects of care for which goals should be defined. As a concrete example, a global approach for cardiovascular diseases should combine both medical risk factor management and a health promotion approach for behavioural changes. In this context, some of the stakeholders suggested that it would be necessary to enhance the practitioners’ knowledge and competencies in these domains. Another key feature of pay for quality programmes is that they should target the full care continuum and need to bridge the gap between clinical care and public health. Global goals of pay for quality programmes that were addressed by the stakeholders were under- and overuse of care services, with an accent on underuse of services. Particular goals that were considered important by the stakeholders included the
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