Pay for Quality

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.