Pay for Quality

156 Pay for Quality KCE Reports 118
9 DISCUSSION
The aim of this study was to comprehend the large body of evidence related to pay for
quality (P4Q), in order to assess feasibility and make suggestions for its implementation
in Belgium. We defined P4Q as the use of explicit and direct financial incentives to
improve quality of health care.
The concept fits in an evolution from “pay for doing things” (fee for service) towards
“pay for doing things right” and “pay for doing the right things” (pay for structure,
process and outcome related aspects) and even to “pay to do right” (in which an
important equity element is present).
In our country so far, the only pilot based application of this direct financial incentive is
related to the improvement of breast cancer screening participation in one Flemish sub
region. Other initiatives, however with a less direct link between the financial incentive
and improved quality of care exist as well, as described in Chapter 7.
The international literature is overwhelmed by the Anglo-Saxon world and the body of
evidence is largely increasing. In addition to that, interviews with international experts
and with local Belgian stakeholders (chapter 8) have finally led to some observations, as
described in the current chapter.
In general terms, we can conclude that the available evidence from the literature shows
that P4Q is no magic bullet. It has the potential to work, with effects sizes mostly
varying between 0 and rather positive, and with a very limited number of negative
results. The methodological robustness of the evidence shows to be variable, ranging
from very weak evidence to strong evidence.
In contrast to evidence on improving average quality, there is lack of evidence on the
reduction of variability in care, yet this is an objective that should be an integral part of
the definition of quality, as also stated by several Belgian stakeholders.
In general, not so many authors have already demonstrated whether P4Q shows
undesired effects.
The impact on equity in health care has only been investigated in the Quality Outcomes
Framework in the UK. The extent to which different patient groups benefit from P4Q
tends to vary and to be highly dependent on the type and complexity of the indicator(s)
under study, the observed patient groups (age groups, males versus females,
socioeconomic groups or ethnic groups), the characteristics of the study (design, level
of analysis, covariates, …) and the level of detail of the studied indicators. Hence, it is
difficult to draw firm conclusions regarding equity. In general, all citizens benefit from
the improvements in quality of care and the extent to which they benefit determines
whether the existing health gap narrows (when the least off have a larger growth than
the best off) or increases (if the least off have a smaller growth than the best off). More
studies suggest a narrowing of the gap, however, for some indicators new gaps arise.
For example a significant difference between the most and least deprived patients
emerged after implementing P4Q for the recording of blood pressure, the recording of
smoking status and giving smoking advice. Also “pre-P4Q” diabetic women were as
likely as men to have their HbA1c, blood pressure, serum creatinine and cholesterol
recorded where post-P4Q inequities in these indicators appeared. Further research is
needed to understand the mechanisms behind these observations.
Cost-effectiveness of P4Q has not been studied widely either, although from a payer’s
perspective it is crucial to know whether the money spent in P4Q was well spent
money.
To answer the main research question of this project, we can state that implementing
P4Q is possible taking into account the considerations made in this report. P4Q
programmes can have value if “organised and implemented in a correct way”, and as an
add-on to other payment mechanisms.