Pay for Quality

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160 Pay for Quality KCE Reports 118 9.3 THE OVERALL HEALTH CARE SYSTEM The overall health care organisation (NHS, managed competition, social security, etc…) may influence P4Q success. National P4Q decision making leads to more uniform P4Q results, as illustrated by the UK example, in contrast with the USA, where different P4Q schemes are not aligned, making it difficult for providers to distinguish the different indicators and involved targets. Belgian stakeholders, focusing on the Belgian healthcare system, where there is (too) much freedom for providers, state that P4Q may serve as a solution to deal with the negative consequences of this freedom. In a system where there is currently too much focus on cure rather than prevention, P4Q may help to improve prevention programmes. With low coordination on chronic conditions, P4Q can offer better task definition and supportive actions. Our conceptual framework suggested that the general system would be of influence on P4Q results. The limited literature with this regard shows mixed evidence. Many other variables act as concurrent mediators, which might cloud theoretically expected relationships. One study reports that higher competition between providers for attracting patients is positively related to both incentives to increase desired services as to incentives to decrease undesired services. In Belgium, it will be important to take into account the existing competition and imbalance between primary and secondary care. P4Q programmes should aim at integrating 1) both levels of care, and 2) cure and prevention. . Chronic diseases can be a good target area to achieve this. 9.4 PAYER CHARACTERISTICS Within a given health care system, payer characteristics can encompass a wide variety of aspects. A pre-existing focus of payers on quality before undertaking a P4Q programme is considered important. It is encouraging to observe that in Belgium many different quality initiatives are currently ongoing, as described in Chapter 7. Adding a payment strategy to most of these programmes that show the intrinsic capability for a true pay for quality programme, can bring us a step forward. For instance, the existing EPA-tool in primary care could be used as a basis for additional payment to GPs when they comply with certain international agreed standards in their structure and organisation of practices. Already existing funds could be redirected in this respect, avoiding new investments. Physicians participating in care itineraries (“zorgtrajecten/trajets de soins”) could receive a bonus if targets for process indicators or intermediate outcome parameters are achieved. The typology of the payer (e.g. private/public) to P4Q results is not reported to be significant in the current P4Q evaluation studies, but admittedly this has received little attention. It could be expected that “for-profit” payers in a competitive environment would be focussed more on cost savings in the short term, and for instance less on equity, while NHS type payers would be focussed more on health targets and equity. 9.5 PROVIDER CHARACTERISTICS There has been a lack of attention for the effects of (dis)congruence of P4Q with professional culture and with physicians’ internal motivation. Through high involvement and democratic decision making when implementing of P4Q it seems that these issues can be addressed, as the UK example shows. But its impact in terms of P4Q results remains unclear, as compared to programmes in other countries where P4Q sometimes was imposed on care providers. Belgium has a tradition of weak confidence between payers and providers. In the opinion of physicians, the design of and the communication about P4Q programmes should avoid a perception of control, interference in practice and punishment.
KCE Reports 118 Pay for Quality 161 According to several stakeholders P4Q may improve a “reflective” attitude among providers, but one should pay attention not to negatively affect the intrinsic motivation of providers to deliver good quality. Whatever the level of involvement, it is clear that a history of engagement by providers – as a group – with quality improvement activities positively influences P4Q results. Programs aimed at the individual provider (or small provider group practices) level, rather than at a hospital level or at a regional or national association, report in general positive results. Incentives that are given on a too high level could create a moral hazard problem. This is in contrast to the opinion of most stakeholders who elicit a preference for group based incentives. Within the small target units, group practices perform better on P4Q than single handed practices according to some studies. However, smaller practice size is also related to other factors such as having patients with poorer health, being located in a deprived area, having more patients from minority ethnic groups, etc. These interrelationships have to be taken into account when assessing the practice size characteristic and its P4Q effects. In the UK there is some evidence that the performance gap between large versus small practices which existed before QOF implementation has disappeared afterwards. There is mixed evidence on the role of the specialty of the provider and little is known about the hospital sector in general. Only a teaching status of a hospital is positively related to P4Q performance, according to one study. 9.6 PATIENT CHARACTERISTICS Both experts and Belgian stakeholders emphasize the importance of taking into account patient characteristics when implementing and assessing P4Q programmes, although this is largely under investigated. For instance, there is a lack of research and evidence on the effects of patient educational status and insurance status. There is also a lack of evidence that patient behaviour in terms of lifestyle, cooperation and therapeutic compliance affects P4Q results or is affected by P4Q programmes. Especially providers point to the fact that they have no complete control on the patient’s role in achieving quality and they express concerns that this may affect their reward. Several stakeholders consider the protection of the patient-doctor relationship in general practice as a core value, and some argue that a revalorisation of intellectual tasks (as opposed to technical tasks) may be achieved partially through P4Q. 9.7 IMPLEMENTATION A necessary condition for implementing P4Q is having funds available, at least by the start of implementation. As the preliminary cost effectiveness results indicate, continuously adding additional funding is no option in the long term. According to the experts it can be useful to model the costs related to a P4Q programme in advance so that cost-effectiveness can be estimated and payers are not confronted with unpleasant surprises afterwards. Another requirement is the stepwise introduction of P4Q. In the UK, this was not the case, which has led to the need to make a number of corrections afterwards on a national scale. In the other countries demonstration projects have been used (or are ongoing) before considering national implementation. Some programmes made use of pay for participation and pay for reporting as a first step. It is however at present too early to tell whether the lessons learned in such a phased approach leads to a higher positive impact of P4Q as a result.
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