Pay for Quality
Pay for Quality
Pay for Quality
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158 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> KCE Reports 118<br />
The choice of the quality target has a substantial influence on the effect of P4Q.<br />
Whereas structural and process targets show in general a more positive effect of P4Q,<br />
this is more difficult to reach <strong>for</strong> intermediate outcome targets (such as HbA1c < 7.4%<br />
in diabetes patients). Yet, on the various types of intermediate outcomes often also<br />
positive effects were found. This contrasts with long term outcome targets <strong>for</strong> which no<br />
significant effects were detected, which can possibly be explained by the fact that these<br />
studies lacked sufficient power, because of the almost zero prevalence of long term<br />
complications combined with the time gap in effect. Long term outcomes require long<br />
term large scale studies or case control studies.<br />
Almost no study indicated that a previously detected quality problem (high variability or<br />
low per<strong>for</strong>mance) on a specific target was the reason to include it in a P4Q programme.<br />
Most studies implicitly referred to general lack of quality without assessing this in a local<br />
context as a first step. A number of studies show an already high per<strong>for</strong>mance at<br />
baseline (e.g. 80 to 90% achievement on certain included measures), which<br />
compromises the effects of the programme, and should be avoided in a possible Belgian<br />
implementation. It is generally accepted by experts and stakeholders that quality<br />
indicators should be evidence based. But an important remark is made by several<br />
stakeholders in that evidence is sometimes too theoretical, and that guidelines are<br />
developed by key opinion leaders. In all day medical practice the theoretical objectives<br />
are not always easy to achieve, and the full meaning of evidence based (not only<br />
scientific evidence, but also context and preferences) is to be taken into account.<br />
Targets should be selected taking into account health care system characteristics and<br />
values. For instance, regarding payments systems, in a fee <strong>for</strong> service system, with<br />
inherent risk <strong>for</strong> overuse, incentives could be related to tackling such overuse. Another<br />
example, regarding heath care objectives/values, in a context of prevention (which is a<br />
regional responsibility in Belgium), the focus should be on tackling clinical inertia (which<br />
is defined as a lack of treatment initiation or intensification in a patient that is not<br />
achieving evidence-based goals of care).<br />
It is striking that most studies are focused on the correction of underuse of appropriate<br />
care, with varying P4Q results, whereas only two studies focus on the overuse of<br />
inappropriate care (lab testing prescription, medical imaging prescription, drug<br />
prescription, etc.). One may state that, if both goals could be better balanced this could<br />
improve the cost-effectiveness of a possible P4Q programme.<br />
There is an evolution in the number of targets and indicators which are included in P4Q<br />
programmes. Programs during the nineties included often only one or a few targets.<br />
Later, this number expanded gradually with the initiation of new programmes (cfr. The<br />
<strong>Quality</strong> Outcomes Framework (QOF) in the UK with almost 150 indicators). The<br />
effect of simplicity vs. complexity of the P4Q programme is difficult to assess, based on<br />
the included studies, and an optimal number of indicators is not really described.<br />
Different weights can be assigned to different indicators according to the workload<br />
related with achieving the target, the potential health gain or cost effectiveness. In the<br />
UK, thus far, only the workload has been taken into account.<br />
According to the international experts, frequent revisions of the indicator set are<br />
necessary, hence targets that are reached can be adjusted and other priority targets can<br />
be included to redirect quality improvement resources.<br />
9.1.2 Measuring quality<br />
The way that quality is measured in a P4Q programme is crucial since it will determine<br />
the incentive consequences. In most studies, data validity and acceptance were reported<br />
as sufficient, perhaps because the decision to initiate a P4Q programme was only taken<br />
in settings with presumed or verified (QOF) data validity and acceptance.<br />
An important concern from the provider’s perspective is the risk that the data are not<br />
sufficiently adjusted <strong>for</strong> practice/hospital and patient characteristics. As a solution <strong>for</strong><br />
this, in the UK the concept of exception reporting was introduced. Yet, there are some<br />
concerns that exception reporting may be “overused” in order to polish the results<br />
somewhat, and that this goes at the cost of equity.