Pay for Quality
Pay for Quality
Pay for Quality
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146 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> KCE Reports 118<br />
reduction of the medical practice variability around guidelines and improvements in<br />
appropriateness of care. Stakeholders stress the importance of finding the right balance<br />
between the relevance of an indicator and the potential effects in providers since<br />
discouragement in providers is to be expected when goals are too difficult to reach and<br />
no improvement in attitude is to be expected when indicators are too easy to reach.<br />
For some stakeholders, the objectives of pay <strong>for</strong> quality programmes should be derived<br />
from existing data and problem areas that could be derived from it. This implies the<br />
need <strong>for</strong> a qualitative / quantitative data in<strong>for</strong>mation system that provides good and<br />
recent overviews of hospital or primary care output. Some even think that the mere<br />
availability of good data could be sufficient to stimulate local creativity so that initiatives<br />
could start from the local needs, based on local epidemiology. For others, goal setting<br />
should stay centrally, and should start from defined, mainly problematic quality<br />
elements, leading to evidence based targets and related indicators<br />
8.2.2.2 Patient populations<br />
Concerning the patient populations that should be targeted in pay <strong>for</strong> quality<br />
programmes, a large consensus was expressed amongst the stakeholders to include<br />
patients with chronic diseases, including e.g. diabetes, cancer, heart failure, cardiovascular<br />
diseases, mental diseases and asthma. It is recognized that these diseases need a<br />
more global, continuous and integrated approach of care.<br />
Global criteria that were defined <strong>for</strong> the selection of target populations were:<br />
prevalence, the availability of data, the existence of guidelines and whether or not there<br />
is room <strong>for</strong> improvement in the quality of care. Some stakeholders mentioned the<br />
importance to have centres of excellence <strong>for</strong> particular chronic diseases.<br />
Preventive care was also often considered as a priority domain to include patients from:<br />
dental care, immunization, smoking and alcohol cessation as well as nutrition related<br />
disorders. Some stakeholders even suggested acute diseases, orphan and rare diseases.<br />
Other classifications that were made by the stakeholders were based on socialeconomic<br />
characteristics of the target population and included disadvantaged persons,<br />
elderly and teenagers.<br />
8.2.2.3 Processes<br />
8.2.3 Incentives<br />
The importance of processes as goals <strong>for</strong> pay <strong>for</strong> quality programmes was recognized by<br />
several stakeholders. However some stakeholders stated that process improvement is<br />
of limited value if it does not lead to outcome improvement. Overall, outcomes seemed<br />
to be ranked much higher compared to processes, but some argue that process and<br />
outcome indicators should be used in a balanced way. A key process that was<br />
mentioned is the integration and coordination of care between the different care levels,<br />
and within the primary care level between primary care physicians and nurses. Less<br />
cited, but probably of no lesser importance were goals including improvements in<br />
adherence to guidelines, knowledge update, rational drug prescription and access to<br />
in<strong>for</strong>mation in patients.<br />
Representatives of patient organizations stress the importance of the Patient’s Rights<br />
Act that is insufficiently known amongst providers, although quality of care is a patient’s<br />
right. A widespread campaign on this topic and a better implementation of its principles<br />
are amongst the goals patient organisations want to support.<br />
The topic of incentives is controversial and stakeholders responded in many different<br />
ways on the question whether or not there is a need <strong>for</strong> incentives. Some stakeholders,<br />
especially from patient organizations, argued that providers are already paid to provide<br />
the necessary quality. <strong>Pay</strong>ing ‘bonuses’ comes down to rewarding what in fact should be<br />
standard of care. Other stakeholders didn’t see any problem or even insisted on the<br />
need <strong>for</strong> incentives in response to quality delivered. The crucial question seemed to be<br />
‘what type of value <strong>for</strong> what type of money’, and more in particular how can we<br />
respond in a cost-efficient way to supplementary gains of quality.