Pay for Quality

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18 Pay for Quality KCE Reports 118 Despite a current lack of consensus, some common ground can be found in literature to divide equity in three domains: equal access to care for people in equal need, equal treatment for people in equal need, and equal treatment outcomes for people in equal need. While this is a simplification of the nature of equity, it is useful in delineating the various domains in which inequities may arise. 64 . An important step when assessing equity in access to care is to formulate an operationally useful definition of access. As indicated by Goddard et al, the precise formulation of ‘access’ is highly contingent on the context within which the analysis takes place. E.g. in the U.S. access is often considered to refer merely to whether or not the patient is insured. Hereby nuances such as the level of insurance or quality levels in care are secondary. In Europe, where most citizens are insured, access is formulated in a more detailed and broader way. 63 According to Goddard et al (2001) ‘access’ refers -at the most general level- “to the ability to secure a specified range of services, at a specified level of quality, subject to a specified maximum level of personal inconvenience and costs, whilst in the possession of a specified level of information”. 63 The aspect of availability and having equal access to a specified range of services or availability of equal services for people with equal need is found in almost every definition of equal access. 63 59 It refers to the fact that age, sex, income, … should not dictate that people with similar needs enter different doors (e.g. public versus private providers) or be treated differently in terms of the type or intensity of services provided. 59 In this definition quality of service is also an intrinsic element of access. Poor quality in terms of the structure, the processes of care or the outcomes might compromise the access to care. For example poor quality of the care process might lead to patient dissatisfaction and result in low compliance. 63 Concerning the aspect of personal inconvenience and cost, and of information, Goddard and Smith (2001) indicate that there might be considerable variations in the personal costs of using services (user fees, transportation costs, …) and in the awareness of the availability and efficacy of services (e.g. because of language or cultural differences). Although completely equalizing personal costs of access and distribution of information, is infeasible, there must be some point when differences in costs and information 63 , 65 distribution become unacceptable. In the assessment of equity in treatment and treatment outcomes, the interaction between patient and provider plays a major role: variations in treatment and treatment outcomes are considered to arise from this interaction which depends on the knowledge, skills, preferences, perceptions, attitudes, prejudices, … of both patient and health care provider 63 . Also the wider social determinants of health such as the social circumstances in which people live and work, might contribute to inequity in treatment and treatment outcomes. For example recovery rates after an operation in different social groups, can occur even when there was no inequity in the access or the treatment that has been provided. 58 For these reasons, analyzing equity in treatment and treatment outcome is complex, and not always feasible. 58 Equity works on the central principle of equal access, treatment, … for people in equal need. 58 . The ‘taxonomy of need’ identifies 4 domains of need. 64, 66 The first domain is ‘normative need’ which is need defined by an expert or professional according to his/her own standards e.g. a guideline (defining e.g. which group is at risk for lung cancer). The second need is the ‘felt need’: the need in which people identify what they want. Important is that felt needs may be limited or inflated by people's awareness and knowledge about what could be available, so, for example, people will not have a felt need for knowing their blood cholesterol level if they have never heard that such a thing is possible. ‘Expressed need’, the third domain, is felt need which has been turned into an expressed request or demand and can therefore be conceptualised as demand for care and – if the demand is fulfilled – care utilisation. Finally, the forth domain, ‘comparative need’, is defined by comparing the user rates of care of different groups of people e.g. screening rates for breast cancer. The group who uses less (in the example with the lowest screening rates) is then defined as being in need.
KCE Reports 118 Pay for Quality 19 This approach simply compares and makes no judgments about the appropriateness or the adequacy of the use in the group with the highest rates, e.g. it is possible that the screening rates in the group with the highest rates, are still not at an adequate level or 64, 66 that there is an overscreening or overtreatment in certain groups. 3.1.1.2 Quality criteria and indicators If the above dimensions of quality are generally accepted, then ideally, each of them should be made evaluable in terms of quality criteria. Thereby, any criterion selected, as well as the desired changes in this criterion, must be policy relevant. 67 In practice, the above definition of quality can be further completed with Donabedian’s distinction of structure, process and outcome quality. But these criteria are clearly not applied to the same extent. Indeed, the quality of structure is often omitted 35 . Structural elements are intended to provide the infrastructure, staff and material resources (including time scheduling) to enable quality improvement processes. These are sometimes also referred to as Care Management Processes (CMPs). The availability of an incident reporting system in patient safety management, the availability of an integrated IT infrastructure with a decision support function, a reminder function, an automatic quality data extraction function, etc. are considered necessary conditions to support the use of specific quality improvement strategies (education, benchmarking, clinical pathway use, etc.) 68 . Moreover, a perceived shortcoming of many P4Q efforts has been the lack of focus on demonstrable benefit — including both health outcomes and spending — as opposed to process-of-care measures 69 . This is likely to be explained by the fact that providers may be more confident that they can control processes of care than outcomes 38 . Numerous external factors (e.g. patient lifestyle, patient compliance, and many non healthcare related factors) influence health outcome. It is therefore hard, and according to some authors unethical or unacceptable, to assign full responsibility for patient long term health outcomes to a provider or team of providers. However, the relationship between structure and process measures and long term patient outcome measures is scarcely grounded in scientific evidence 70 , 71 , 72 , 73 . Therefore, overly relying on structure and process outcomes threatens the credibility of a P4Q system. It instils doubt that the programme will do what it is intended to do: to maintain or improve quality of care, which is mostly patient outcome and patient experience based (the global health of the patient). This choice between structure/process indicators and outcomes indicators corresponds with the distinction between efforts versus result based assignment of responsibilities. As in most P4Q design decisions a combined approach is also possible, and used in most programmes. As important as the choice of criteria is the final number of criteria applied in the P4Q programme. Rosenthal et al (2005) point out that too few criteria may lead to drawing the attention away of many aspects of medical practice that are not covered by the selected criteria, while too many criteria will lead to organisational complexity 74 . With this regard, some authors refer to the term “multitasking” 75 , 76 . If the goal of the payer is multidimensional, but not all dimensions lend themselves to measurement, then rewarding performance based on available measures will distort the efforts away from the immeasurable objectives. This has also been described earlier by Conrad et al (2004) 35 . Once criteria have been selected, the desired value for each of the criteria reflects the specific goals (or targets) of the P4Q programme, the achievement of which can be measured by quality indicators. Quality targets can be directed at improving current underuse, overuse or misuse of treatment. The definition of appropriate vaccination rates is an example of the first, the definition of appropriate lab testing and medical imaging use is often an example of the second. We will see that almost all current P4Q programmes focus on underuse.
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