Pay for Quality

KCE Reports 118 Pay for Quality 11
2.1.2 Selection of and data-extraction from articles related to equity
To describe the equity dimension of P4Q models a selection of publications from the
main database was selected from the above evidence table. Afterwards two reviewers
(SW and PB) performed an independent full text analysis. Publications labelled as
“doubtful relevance concerning the impact on equity” by one of the two reviewers,
were discussed between the reviewers until consensus was reached. In addition, all
references of relevant equity articles were once again screened for additional material
and one publication was added.
In a second phase the researchers (SW and PB) assessed how equity is conceptualized
in the studies (to what extent did the selected papers address different domains of
equity and did they conceptualize equity as vertical or horizontal or both?). To do this
systematically, the researchers developed a grid which includes all equity-related
concepts identified as essential (see appendix 10).
2.1.3 Revision of the conceptual framework into an evidence based state of the
art framework
After the results were available from the conceptual framework construction and from
the systematic review of the P4Q evidence base (equity dimension as well as all other
quality dimension), both were integrated by relating the evidence base to the theoretical
assumptions. The initial framework was assumed to be a set of hypotheses to be
confirmed or disconfirmed by empirical findings.
When confronting theory with evidence, it is important to consider both the internal
validity as the external validity of the findings. The internal validity is guarded by the
previous ‘hard’ approach using a systematic review process. However, as suggested by
Leontien et al (2008), this is combined with a Realist Evaluation Approach (see
publications by Pawson & Tilley) to address external validity 33 . This approach addresses
the question of what works for whom in what circumstances? Measures are expected
to vary in their impact depending on the conditions in which they are introduced.
Realistic evaluation assumes that mechanisms supporting an intervention are activated
by conditions and can explain observed patterns in outcomes. These configurations are
also known as context mechanism regularities which can be explored to uncover the
‘black box’ behind an intervention as P4Q.
Both underlying mechanisms (more practically than fundamentally behaviourally
approached) and contextual factors are identified in the conceptual framework. During
the revision process these were specifically related to evidence on outcomes. Missing
links are also identified. The results can be consulted in Chapter 5.
2.1.4 Consultation of international experts as P4Q involved country
representatives
For the international comparison study (chapter 6) four countries are taken into
account, namely the USA, the UK, the Netherlands and Australia. 6 experts were
chosen, based on their expertise with P4Q. For the USA and the UK, 2 key experts per
country were invited to participate. For the Netherlands and Australia, two countries
which are still in a starting phase of implementing P4Q, with only a few P4Q schemes
operational, only 1 key expert per country was invited to participate.
Prof. Rosenthal and Prof. Damberg acted as US experts. The last 10 years Prof.
Rosenthal has been working as a health care economist at the Harvard school of public
health. Most of her work is related to provider-payer incentives. Her research focuses
primarily on Pay For Quality and other payment mechanisms like capitation and FFS.
Dr. Damberg is a health services researcher, who works at a non profit US think-thank,
named RAND. In the past she has worked for both the federal government doing health
policy work, as well as for the private industry. Her main areas of interest are
measuring quality and performance of the health system, patient safety, consumerdirected
health plans, and assessing the impact of health care reform initiatives on
quality and costs. Since 1992 most of her research has focused on Pay For Quality.