Pay for Quality
Pay for Quality
Pay for Quality
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160 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> KCE Reports 118<br />
9.3 THE OVERALL HEALTH CARE SYSTEM<br />
The overall health care organisation (NHS, managed competition, social security, etc…)<br />
may influence P4Q success. National P4Q decision making leads to more uni<strong>for</strong>m P4Q<br />
results, as illustrated by the UK example, in contrast with the USA, where different P4Q<br />
schemes are not aligned, making it difficult <strong>for</strong> providers to distinguish the different<br />
indicators and involved targets. Belgian stakeholders, focusing on the Belgian healthcare<br />
system, where there is (too) much freedom <strong>for</strong> providers, state that P4Q may serve as<br />
a solution to deal with the negative consequences of this freedom. In a system where<br />
there is currently too much focus on cure rather than prevention, P4Q may help to<br />
improve prevention programmes. With low coordination on chronic conditions, P4Q<br />
can offer better task definition and supportive actions.<br />
Our conceptual framework suggested that the general system would be of influence on<br />
P4Q results. The limited literature with this regard shows mixed evidence. Many other<br />
variables act as concurrent mediators, which might cloud theoretically expected<br />
relationships.<br />
One study reports that higher competition between providers <strong>for</strong> attracting patients is<br />
positively related to both incentives to increase desired services as to incentives to<br />
decrease undesired services.<br />
In Belgium, it will be important to take into account the existing competition and<br />
imbalance between primary and secondary care. P4Q programmes should aim at<br />
integrating 1) both levels of care, and 2) cure and prevention. . Chronic diseases can be<br />
a good target area to achieve this.<br />
9.4 PAYER CHARACTERISTICS<br />
Within a given health care system, payer characteristics can encompass a wide variety of<br />
aspects.<br />
A pre-existing focus of payers on quality be<strong>for</strong>e undertaking a P4Q programme is<br />
considered important. It is encouraging to observe that in Belgium many different quality<br />
initiatives are currently ongoing, as described in Chapter 7. Adding a payment strategy<br />
to most of these programmes that show the intrinsic capability <strong>for</strong> a true pay <strong>for</strong> quality<br />
programme, can bring us a step <strong>for</strong>ward. For instance, the existing EPA-tool in primary<br />
care could be used as a basis <strong>for</strong> additional payment to GPs when they comply with<br />
certain international agreed standards in their structure and organisation of practices.<br />
Already existing funds could be redirected in this respect, avoiding new investments.<br />
Physicians participating in care itineraries (“zorgtrajecten/trajets de soins”) could receive<br />
a bonus if targets <strong>for</strong> process indicators or intermediate outcome parameters are<br />
achieved.<br />
The typology of the payer (e.g. private/public) to P4Q results is not reported to be<br />
significant in the current P4Q evaluation studies, but admittedly this has received little<br />
attention.<br />
It could be expected that “<strong>for</strong>-profit” payers in a competitive environment would be<br />
focussed more on cost savings in the short term, and <strong>for</strong> instance less on equity, while<br />
NHS type payers would be focussed more on health targets and equity.<br />
9.5 PROVIDER CHARACTERISTICS<br />
There has been a lack of attention <strong>for</strong> the effects of (dis)congruence of P4Q with<br />
professional culture and with physicians’ internal motivation. Through high involvement<br />
and democratic decision making when implementing of P4Q it seems that these issues<br />
can be addressed, as the UK example shows. But its impact in terms of P4Q results<br />
remains unclear, as compared to programmes in other countries where P4Q sometimes<br />
was imposed on care providers.<br />
Belgium has a tradition of weak confidence between payers and providers. In the<br />
opinion of physicians, the design of and the communication about P4Q programmes<br />
should avoid a perception of control, interference in practice and punishment.