Pay for Quality

150 Pay for Quality KCE Reports 118
8.2.5.2 Risk adjustment
8.2.5.3 Indicators
A sufficient case-mix within the targeted populations was important for some
stakeholders, mainly for general practitioners, patients, insurers and health care
authorities. Thus, the risk-adjustment is considered a preliminary condition for pay for
quality programmes. To avoid the exclusion of so called ‘unwanted patients’, an
exception reporting should be foreseen.
General consideration about indicators
Many of the stakeholders knew about existing quality indicators. They think that a global
assessment tool is needed for the development of a reliable and evolving data set. One
stakeholder suggested the construction of personal indicators in primary care, using the
“Lot Quality Assessment Sampling” (LQAS) method, allowing general practitioners to
perform a self-assessment on their own databases. The aim would be to support
voluntary quality improvement, but also to reduce existing barriers, i.e. the fear of
control from the NIHDI.
Structure indicators
Although the quality of structural elements of care is often omitted in current quality
programmes, some stakeholders argue that these elements are fundamental to both
hospital settings and primary care. For the latter, it is stated that they are the easiest to
assess. As primary care has no approach on diseases as such, but in terms of global
individual care, the European Practice Assesment tool for primary care focuses includes
a lot of mainly structural indicators. Examples that were cited for hospital and primary
care were: size and satisfaction of staff, complementary services to patients in hospitals,
data structure and coding and level of computerization in primary care, availability of up
to date material and systems for updating guidelines.
Process indicators
For some stakeholders (general practitioners, hospitals) process assessment and
process indicators would seem to be more acceptable compared to outcome indicators
since they are more easily controllable and because of their shorter delay for
assessment. Moreover, outcome targets are often appraised as specialists’ targets
whereas general practitioners think more global, accepting much more diversity, and
integrate their services and those from others around a specified patient. Quality
assurance in general practice needs a global approach valorising existing routines and
patient communication. Examples of structure and process indicators that were given
were: medical record management, number of global medical records, antibiotic
prescription, guideline adherence, permanence of care, duration of consultations,
immunization rate, and access time from admission to diagnosis in hospitals and staff
scientific activities.
Outcome indicators
A lot of resistance was expressed on outcome assessment and outcome indicators
because of the technical difficulties of this assessment, (especially in primary care), the
tendency to come forward with false results (because of the link to financial incentives)
and the role of the patient in his/her adherence to the medical treatment regimen.
Outcome indicators that were cited were: disease-free survival, quality of life,
nosocomial infections rate, accuracy in diagnosis, iatrogenic death and surgical errors.
We can refer again to the KCE report 85A on capitation versus fee for service
payment, whereby several possible outcomes indicators are listed.