Pay for Quality

4 Pay for Quality KCE Reports 118
1 BACKGROUND AND OBJECTIVES
Research into the quality of healthcare is producing increasing amounts of evidence
1 , 2 , 3 , 4 , 5 , 6 , 7
about treatment underuse, overuse and misuse.
8 , 9
Unintended variability in processes and outcomes were also reported in Belgium,
and current strategies to tackle these problems do not show clear results. 10 , 11 One of
the most important characteristics of any health system are the financial driving forces.
However, ‘Fee for service’, ‘capitation’ and ‘prospective payment’ may influence mainly
quantity instead of quality. As a result several studies indicate that current payment
12 , 13 , 14
systems insufficiently reward the delivery of good care.
One proposed intervention is to directly relate the remuneration of delivered care to
the achieved result on structure, process and/or outcome indicators. This mechanism is
known as ‘pay for performance’ (P4P) or ‘pay for quality’ (P4Q) (when focusing
exclusively on the quality component of performance). The Institute of Medicine (2007)
(IOM) explains P4Q as ‘the systematic and deliberate use of payment incentives that
recognize and reward high levels of quality and quality improvement’ 2 . Quality is
defined as: ‘The degree to which health services for individuals and populations increase
the likelihood of desired health outcomes and are consistent with current professional
knowledge’. It consists of different dimensions, namely clinical effectiveness of care,
interpersonal aspects of care, patient safety, access and equity of care, continuity and/or
coordination of care and cost-effectiveness of care.
There is an increasing amount of evidence related to P4Q programmes. However, these
programmes are very heterogeneous with regard to the type of incentive, the target
health care providers, the applied criteria for quality, the way the programme is
implemented and evaluated and the contextual aspects related to the programme.
Several systematic reviews have already been published aiming at finding evidence on
what works and what does not. At the same time different authors have tried to create
a conceptual and theoretical framework, which could serve as a basis for the design of
new programmes.
In Belgium, the interest in P4Q is observed as well, as witnessed by some initiatives.
However, it is felt that without learning from lessons abroad, and the absence of a clear
conceptual framework applicable to the Belgian setting, such initiatives may not reach
the desired goals for which they are (or should be) intended.
Therefore, the purpose of this project is to answer the following key research
questions:
What can be learned from the international P4Q literature regarding the design,
implementation and evaluation?
• Design and implementation. What are the current system components of a
P4Q programme? How are financial incentives designed? What are the critical
success factors for the implementation of a P4Q programme?
• Evaluation. What are the effects of the use of P4Q programmes, focusing on
all relevant quality domains (including access, coordination, equity, costeffectiveness,…)
and also taking into account unintended consequences?