Pay for Quality

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162 Pay for Quality KCE Reports 118 A number of studies relate absence of P4Q effects to an absent or insufficient awareness and poor communication. Studies that used more extensive and direct transparent communication about P4Q to the involved providers found more positive effects. Involvement of all stakeholders, in the first place the providers themselves, when developing the P4Q programme proved important, but findings remain mixed (sometimes positive, sometimes no effect). Experts and Belgian stakeholders clearly confirm this need for communication, creating awareness and obtaining involvement. For successful implementation, stakeholders insist that centrally conceived programmes should be supported by decentralised availability of knowledge, qualified support and local organised input like quality management skills in hospital and primary care, and performing IT systems at all levels. The role of medical leadership in supporting the P4Q programme is potentially influencing motivation and therefore effectiveness of a P4Q programme, but is rarely reported upon in the studies. Belgian stakeholders considered the role of leadership crucial. 9.8 TOWARDS P4Q IN BELGIUM? Although many P4Q studies show design problems, leading to mixed evidence on several aspects, elements that ideally should be taken into account when undertaking P4Q initiatives in Belgium can be listed. P4Q should not be started simply as a nice new idea. It should be made clear why to start, what the current quality issue is, and how it could be addressed with a P4Q programme. Already in this process, all stakeholders should be involved and consulted. A first key aspect is the definition of quality. The following aspects appear to be of importance, either based on theoretical grounds, or supported by evidence, experts or stakeholders: • Quality is more than just clinical effectiveness; the different dimensions of quality should be kept in mind. The quality definition and conceptualisation should be in line with both the health system and the provider values. • When translating quality into indicators, structure, process, and intermediate outcome indicators should all be considered, since they all have their own value (e.g. IT adoption enhancement as a structural goal). But they should all be supported by evidence, and by evidence on room for improvement. • Consider both increasing appropriate care (reducing clinical inertia) and reducing inappropriate care. In some circumstances, maintaining quality can also be an option. • Plan already next targets when current targets have been largely achieved (i.e. following a plan do check act approach). The way that quality achievement will be measured, must also be planned. The following could be taken into account: • Make use of accurate and validated data, for instance by investing in IT development, and making data collection automatic • Make use of data already available as much as possible • Monitor potential unintended consequences (especially in care equity, patient experience and provider experience) • Apply case mix adjustment on intermediate outcome measures. • Apply exception reporting to guard individualized care. • Provide an audit system to prevent and detect gaming. This, together with most of the above elements, requires a well established health information system. • Include both baseline and comparison group measurements (in the initial phase)
KCE Reports 118 Pay for Quality 163 • Take into account the experience of the patient as part of the targets, and during programme development, implementation and evaluation. Several reflections about the type of incentive can be made: • Make use of rewards. Of course this also means no payment in case of any performance. The size of this reward could be up to 10% of total payment. • Find an acceptable balance between rewarding high achievement and rewarding improvement reward both best performers and best improvers. • Incentives should be weighted in accordance with the supplementary effort needed to achieve the supplementary quality but also with societal importance (health impact/cost-effectiveness). • Target incentives at least at the individual provider level, but combine individual incentives with team based incentives when appropriate (to stimulate inter provider collaboration). • Keep the incentive scheme as simple as possible and easy to communicate • Make use of a non competitive approach. Budget control can be guarded by applying a corrective factor on all P4Q incentive payments, equal in size for all participants. The next challenge is to implement gradually the programme, taking into account health care system, payer, provider and patient characteristics. The following could be recommended with this regard: • Avoid a “one shot”, but make use of a cyclical, dynamical quality improvement approach. • Use a phased approach, i.e. start with a pilot programme, of which lessons can be drawn in preparation of the full programme. “Pilot” can mean a limited region, or it can also mean starting with a limited number of indicators. • Develop P4Q schemes starting from or together with other quality improvement initiatives. • Provide a uniform P4Q system (in which local target priorities may vary) from all payers to all participating providers to support transparency, awareness and a sufficient incentive size. • Make support (for instance IT support), knowledge and qualification available at the local level. • When implementing P4Q, the medical profession needs to be involved from the start. • Take into account the level of congruence with professional culture, but realize that P4Q may also support a cultural shift. • Communicate and create awareness around the planned programme. Finally, no programme should be started without a guarantee for a correct assessment of its overall impact. It is no use to invest in a P4Q programme when the invested money does not proportionally lead to benefits (either savings or improved health). Therefore: • Build in a mechanism to avoid exceeding the budget. For instance, a fixed budget to spend in the form of rewards, whereby the reward per provider is smaller when more providers meet the objectives. • Estimate the cost-effectiveness of the programme already before starting • Build in a post hoc evaluation of effectiveness and cost-effectiveness of the programme using scientifically valid methods. In conclusion, we could state, along with several Belgian stakeholders, that well conceived and transparent quality initiatives can contribute to the legitimacy and costeffectiveness of the health care system. Pay for quality might therefore provide a new meaning to accountability at both the system and individual level.
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