Pay for Quality

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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.
KCE Reports 118 Pay for Quality 151 8.2.6 Evaluation of the programme 8.2.6.1 Sustainability of change One GP stakeholder mentioned that objectives of pay for quality programmes should be realistic, in the sense that the objectives of the programme should attainable by most actors involved. The latter is considered a critical success factor of the programme. Another stakeholder (insurer) stressed the importance of practical learning and sharing of experiences to sustain the programme. 8.2.6.2 Validation of the programme Some stakeholders stated it is important to define in a precise way the objectives of the programme, its standards and quality dimensions in order to assure a solid evaluation of the programme. Other criteria that were considered important for the evaluation of the programme were the participation rate, satisfaction of the participants as well as the budgetary impact on the target population. Effectiveness and efficiency of the programme could also be measured through reports on morbidity and mortality, and intermediary outputs. Various agencies were put forward to do this evaluation including the KCE, a centralized agency or international experts working for a European agency. 8.2.6.3 Review and revising the process Stakeholders mentioned the need of an initial assessment of the current situation and continuous monitoring of the programmes to detect positive or unintended effects. This should be coordinated at a central (regional or federal) level and based on good cooperation of the professionals. 8.2.6.4 Financial impact and return on investment For most stakeholders, considering the huge part of the Gross Domestic Product allocated to health, the cost of P4Q programmes should be included in the current budget of the health system with a re-allocation of the current means e.g. from the accreditation budget. One stakeholder pointed out that a particular part of the budget for primary care that is usually not spent should be used to finance pay for quality programmes in primary care. Some stakeholders highlighted the need for initial and substantial investments at the start of pay for quality programmes. Return on investment and long-term savings should be considered next. Obviously, a programme should only be undertaken once the expected return on investment and cost-effectiveness has been calculated. 8.2.6.5 Unintended consequences Patient selection A major unintended consequence that was highlighted by many stakeholders was the risk for patient selection in providers. A second risk as mentioned by the stakeholders was data gaming. There seems to be an apparent lack of trust in providers as expressed by stakeholders from the government, but the issue of data gaming was however expressed by many stakeholders from all settings. Exception reporting is considered important as one must avoid undue penalties of providers when compliance in patients to the medical regimen is poor or absent (confirmed by poor outcomes in indicators). On the other hand exception reporting seems important to follow-up on ‘difficult’ patients. Other potential issues that were raised by a lot of stakeholders were the risk for disinterest for problems which are not linked to incentives, which consequently means that pay for quality programmes should target a wide range of diseases. Second, there is a risk for disintegration of care in the sense that a holistic approach towards the patient is less applied. A strong focus on processes and services and the multidisciplinary aspect of care is considered helpful to overcome this risk.
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