Pay for Quality

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.