Pay for Quality

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158 Pay for Quality KCE Reports 118 The choice of the quality target has a substantial influence on the effect of P4Q. Whereas structural and process targets show in general a more positive effect of P4Q, this is more difficult to reach for intermediate outcome targets (such as HbA1c < 7.4% in diabetes patients). Yet, on the various types of intermediate outcomes often also positive effects were found. This contrasts with long term outcome targets for which no significant effects were detected, which can possibly be explained by the fact that these studies lacked sufficient power, because of the almost zero prevalence of long term complications combined with the time gap in effect. Long term outcomes require long term large scale studies or case control studies. Almost no study indicated that a previously detected quality problem (high variability or low performance) on a specific target was the reason to include it in a P4Q programme. Most studies implicitly referred to general lack of quality without assessing this in a local context as a first step. A number of studies show an already high performance at baseline (e.g. 80 to 90% achievement on certain included measures), which compromises the effects of the programme, and should be avoided in a possible Belgian implementation. It is generally accepted by experts and stakeholders that quality indicators should be evidence based. But an important remark is made by several stakeholders in that evidence is sometimes too theoretical, and that guidelines are developed by key opinion leaders. In all day medical practice the theoretical objectives are not always easy to achieve, and the full meaning of evidence based (not only scientific evidence, but also context and preferences) is to be taken into account. Targets should be selected taking into account health care system characteristics and values. For instance, regarding payments systems, in a fee for service system, with inherent risk for overuse, incentives could be related to tackling such overuse. Another example, regarding heath care objectives/values, in a context of prevention (which is a regional responsibility in Belgium), the focus should be on tackling clinical inertia (which is defined as a lack of treatment initiation or intensification in a patient that is not achieving evidence-based goals of care). It is striking that most studies are focused on the correction of underuse of appropriate care, with varying P4Q results, whereas only two studies focus on the overuse of inappropriate care (lab testing prescription, medical imaging prescription, drug prescription, etc.). One may state that, if both goals could be better balanced this could improve the cost-effectiveness of a possible P4Q programme. There is an evolution in the number of targets and indicators which are included in P4Q programmes. Programs during the nineties included often only one or a few targets. Later, this number expanded gradually with the initiation of new programmes (cfr. The Quality Outcomes Framework (QOF) in the UK with almost 150 indicators). The effect of simplicity vs. complexity of the P4Q programme is difficult to assess, based on the included studies, and an optimal number of indicators is not really described. Different weights can be assigned to different indicators according to the workload related with achieving the target, the potential health gain or cost effectiveness. In the UK, thus far, only the workload has been taken into account. According to the international experts, frequent revisions of the indicator set are necessary, hence targets that are reached can be adjusted and other priority targets can be included to redirect quality improvement resources. 9.1.2 Measuring quality The way that quality is measured in a P4Q programme is crucial since it will determine the incentive consequences. In most studies, data validity and acceptance were reported as sufficient, perhaps because the decision to initiate a P4Q programme was only taken in settings with presumed or verified (QOF) data validity and acceptance. An important concern from the provider’s perspective is the risk that the data are not sufficiently adjusted for practice/hospital and patient characteristics. As a solution for this, in the UK the concept of exception reporting was introduced. Yet, there are some concerns that exception reporting may be “overused” in order to polish the results somewhat, and that this goes at the cost of equity.
KCE Reports 118 Pay for Quality 159 A related concern from the payer’s perspective is the risk of “gaming”, i.e. wrong or biased reporting. The data collection should therefore be organized as such that gaming becomes almost impossible, for instance by extracting data automatically out of the electronic health record and by setting up an audit system. Because of the workload associated with data collection, it is preferred to make use of existing data as much as possible. Quality measurement also involves attention for other unintended consequences such as patient selection or shifting attention away from other, unincentivized, healthcare quality priorities. Monitoring of unintended consequences remains therefore important in any new initiative. It should be clear that careful selection of indicators, together with structural investments in data monitoring and quality management are necessary conditions for P4Q to become successful, as was also stated by the Belgian stakeholders. With this regard, the current lack of integration of existing data, the difficulties to use these for epidemiological purposes and the cumbersome process of obtaining data for research are a key problem, as stated by several stakeholders. 9.2 INCENTIVE The cornerstone of any P4Q project is the incentive itself. This incentive can be characterized by different aspects such as the size, the nature (bonus or penalty), the frequency, etc… Incentives of a purely positive nature (rewards) seem to have generated more positive effects than incentive schemes using a competitive approach (in which there are winners and losers). Both international experts as most Belgian stakeholders support rewards rather than penalties. This seems quite logic, but it should be realised that applying rewards entails automatically higher investments, and it should be assessed whether these investments are cost-effective. Another issue is whether to reward best improvers (those who make the best progress versus the baseline) or best performers (those who achieve a fixed threshold, e.g. >80% of patients with HbA1c below a given level). It is felt by both international experts and Belgian stakeholders that both should be rewarded. The evidence from literature is mixed in this regard. At present the included studies do not enable to make a further distinction on the effects of different incentive structures (bonus, fee schedule, withhold, regular payment increases, and quality grants), nor is there a clear relationship between incentive size and reported P4Q results. Workable incentive sizes seem to add 5 to 10% to the current income level of the health care providers. Not surprisingly, stakeholders representing provider organisations argued for substantive rewards, whereas stakeholders representing payers stressed more the need for cost control (hence small incentives). There is an absence of evidence with regard to the choice between direct income stimuli and quality improvement investment stimuli, due to a lack of programmes and studies including the second option. The Quality Outcomes Framework in the UK, which led to mainly positive effects, is based on a combination of both. Practices receive a bonus as part of their operational revenues and can use it to reinforce the practice resources, tools and infrastructure and/or to allocate additional income to individual physicians. This has led to major investments by practices in staffing. A key question is how frequent incentives should be given and for how long. There is not much evidence with that regard. Based on expert and stakeholder findings, it is advised to opt for a programme in which incentives are given on predefined time points with a sufficient duration over time. In this light it will be interesting to follow up the long term effects of the current Flemish initiative related to breast cancer screening.
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