Pay for Quality

KCE Reports 118 Pay for Quality 149
8.2.3.6 Target unit (individual, group / organisation …)
The majority of stakeholders indicated that it is not the individual level of care that
should be targeted in pay for quality programmes. Targeting the individual level would
be labour-intensive, and would lead to avoiding strategies by providers and probably
endless debates on cause-effect relationships with regard to clinical outcomes.
Incentives should be directed at professional groups as a whole or to teams as they will
facilitate and improve the debate between peers on how to improve the quality of care.
Instruments and strategies that were mentioned by several stakeholders in the context
of targeting individuals and groups were feed-back and benchmarking.
No specific numbers were mentioned by the stakeholders with regard to the size of
units that should be targeted. Examples of levels that were mentioned by the
stakeholders were the loco-regional level and the hospital level.
8.2.4 Target audience for P4Q programmes
As target audience for pay for quality programmes both primary and secondary care
were mentioned. In this context a preliminary assessment of the opportunities and
threats was considered a critical success factor. For some stakeholders among general
practitioners and insurers, the primary care setting is theoretically the first to be
considered, as it would fit with the need to globally strengthening primary care. On the
contrary, if the aim is to seek for economies, the hospital setting is to be considered as
some stakeholders think the available budgets aren’t spent in an efficient way.
The coordination between primary and secondary care seems to be an important target
for some stakeholders representing hospitals, general practitioners and the NIHDI. The
current dissymmetric level of empowerment and available budgets between primary and
secondary care makes it however difficult to collaborate.
8.2.5 Quality measurement in P4Q programmes
8.2.5.1 General considerations on quality measurement
Although it is often said that Belgium has the best health care system in the world,
stakeholders criticize this statement. The perception that our system delivers high
quality of care might result from the existing overuse of services and the absence or
limited waiting lists. Shortcomings of our health care system is that we do not have
sufficient and reliable data and the fact that indexes of performance in specific care
needs are established by private companies abroad (e.g. Health Consumer
Powerhouse). Insurers’ and trade unions’ stakeholders do agree on the opportunity that
pay for quality programmes represent in terms of quality improvement in order to
ensure legitimacy and cost-effectiveness of the health system. On the other hand many
stakeholders assume that pay for quality will be difficult to perform because of e.g. the
variety of determining factors of quality, the complexity of clinical care and case
management and the delays between actions and outcomes in preventive care. A
crossover action of different databases, at the local and regional level, will probably be
necessary to avoid under- or overestimation. A remaining problem is the difficulty to
delimit the customer or population base of general practitioners, mainly in the French
part of Belgium, due to the limited use of the global medical record.
There is a general conviction that good indicators can be built from a current set of
measures. The set of indicators used for the KCE study 85B (Comparison of cost and
quality of two financing systems in primary health care in Belgium - 2008) represents for
some stakeholders the best that is available in Belgium.
For some stakeholders, quality measurement should feed a data collection system,
aimed at scientific research and feedback to the providers. In this context, the
combination of self-assessment (with easy-to-use tools) and an external accreditation
system seems to be effective.