Pay for Quality

KCE Reports 118 Pay for Quality 17
A former KCE report by Vlayen et al. (2006) proposed the following dimensions of
quality of care 56 .
• Safety: avoiding injuries to patients from the care intended to help them;
• Clinical effectiveness: the professionals giving care should be competent,
provide services based on scientific knowledge to all who could benefit and
refrain from providing services to those not likely to benefit;
• Patient centeredness: providing care that is respectful of and responsive to
individual patient preferences, needs, and values and ensuring that patient
values guide major clinical decisions;
• Timeliness: avoiding waits and potentially harmful delays;
• Equity of care: services should be available to all people and care should not
vary in quality because of personal characteristics such as gender, ethnicity,
geographic location, and socioeconomic status (this is elaborated more below);
• Efficiency of care: the society should get value for money by avoiding waste,
such as waste of equipment, supplies, ideas, and energy;
• Continuity and integrativeness: all contributions should be well integrated
to optimise the delivery of care by the same healthcare provider throughout
the course of care (when appropriate), with appropriate and timely referral
and communication between providers.
This approach goes much broader than the strict “clinical outcomes” approach.
Especially the focus on equity could be considered as an implicit criticism to the neoclassical
way of thinking as if effectiveness and efficiency should be the major values of
any health care system.
In addition to the above mentioned dimensions of quality of care, quality on a global
level also involves reducing variability in care 55 , 57 .
P4Q involves an evolution of payment systems from “pay to do things” towards “pay to
do things right”. However this view could further evolve to “pay to do the right things”
and even simply “pay to do right”.
Equity has received special attention in this project. From the beginning the research
group took a special interest in assessing the impact of a P4Q programme on equity.
Indeed from a Belgian point of view this seemed a rational choice. Inequities in health
concern systematic differences in health status between different groups (men versus
women, age groups, socio-economic groups, …). Inequities in health are systematic (not
distributed randomly), socially produced (social processes and not biological processes
produce these variations in health) and considered to be unfair because they are
generated and maintained by unjust social arrangements. 58 In this context the concept
of “substantive equity” refers to the minimization of disparities in health among
subgroups. 59
When striving to reduce inequities in health, policies should be designed in ways most
likely to move toward equalizing the health outcomes of disadvantaged social groups
with the outcomes of their more advantaged counterparts 60 .This means that the only
strategy to narrow the health gap in an equitable way is to bring up the health level of
those who are worse off. This concept has also been called levelling-up 61 , 62 .
Inequity in health care is one of the many determinants of inequities in health. 58
(In)equity in health care is a central point of attention of many health care systems and
tackling this inequity has been an important objective in the development and
reorganization of health services. 63
There is a large amount of literature on how to conceptualize and measure equity in
health care.