Pay for Quality

KCE Reports 118 Pay for Quality 157
More specifically, our conclusions can be framed according to the conceptual model
that was presented in Chapter 3. This model was developed to represent all relevant
aspects of Pay for Quality and its application in practice. Central in the model is the
relationship between the desired quality increase (or maintenance if already a high
level was achieved) and the incentive that is to be paid. The nature of the incentive
and the way that quality is defined and measured can be quite different between
programmes. As important is the relationship between the payer (who will execute the
incentive) and the health care provider (who is the target for the incentive and who is
supposed to increase or maintain quality of care). Here again, the characteristics of
these stakeholders and their relationship will affect the success of a P4Q programme.
The model moreover emphasized the need to account for characteristics of the
patients, as well as the overall health system (i.e. social security or NHS, type of
prevailing physician payment system, etc…).
The implementation of the programme must follow a “Plan Do Check Act” (PDCA)
logic, in which room and efforts are foreseen to regularly seek input from all
stakeholders involved and undertake a continuous evaluation of the programme’s
effects.
The reader should note that conclusions based on evidence from P4Q studies should be
regarded with caution because the effect of a P4Q programme can depend from so
many factors (incentive size, choice of indicators, involvement of practitioners …) that
it is difficult to assign success or failure to one specific aspect of a programme. Modern
healthcare organisation should be considered a complex network. Actual complexity
research shows that single focused interventions never show simple linear effects.
9.1 QUALITY
9.1.1 Defining quality
In this study, we have defined quality in all its aspects: patient safety, clinical
effectiveness, patient centeredness, timeliness, equity and access of care, efficiency and
finally continuity and integration. However, only two quality domains are mainly focused
upon in P4Q evaluation studies: clinical effectiveness and – to a lesser extent - equity of
care. The latter is moreover poorly defined in most studies.
Only a few studies focussed on continuity and integration, with positive effects. Also
Belgian stakeholders stated that quality is a transmural concept with strong emphasis on
integration.
A disease related focus differs from a more generic focus. Most reported initiatives
focus on specific diseases or defined medical problem areas, like diabetes or breast
cancer screening. Some are more global and support a more generic involvement in
quality issues, like the EPA-initiative in primary care and the Quality and Safety
framework for hospitals.
Indicators for quality can relate to structure (e.g. availability of sufficient staff), process
(e.g. timely measurement of blood parameters) and outcome (the actual patient’s health
results).
Current P4Q studies make mostly use of process and intermediate outcome indicators.
Structural indicators are used to a lesser extent. Long term outcome indicators are
used very rarely. Most evidence comes from primary care (with recently an increase in
hospital based studies) and most studies are observational in nature (with a limited
number of comparative interventional studies).