Pay for Quality

20 Pay for Quality KCE Reports 118
It has been noted by Duckett et al. (2008) that some programmes may adversely
encourage overutilization or unnecessary diagnostic testing 67 . Hence, before setting
criteria related to one or more quality dimensions, it must be fully documented that
these criteria are in line with the current knowledge base regarding the optimisation of
these dimensions.
Regardless of the above issue, targets must be SMART (specific, measurable, achievable,
relevant, and timely) 67 , 77 .
Rather than using explicitly the SMART terminology, Dudley and Rosenthal (2006) state
that following questions should be asked when deciding on quality targets and hence
indicators. 78
1. Does the indicator measure care that is a priority for quality improvement?
2. Does the indicator reflect technical competency or patient experiences with
care?
3. Is the indicator actionable?
4. Is there a valid source for the data needed to calculate the indicator? What is
the cost of acquisition and validation of those data 79 ?
5. Is the indicator accepted by the medical community?
With regard to “achievable” or “actionable”, the challenge is to find an optimal
achievement level thereby considering that there must be sufficient room for
improvement on the one hand, but that the target must be realistic and achievable on
the other hand 38 , 67 . The “Measurable” part of the SMART concept is discussed in the
next paragraph.
3.1.1.3 Quality measurement
The desired behaviour must also be measurable, which involves that valid and
comprehensive management information systems to track performance against the goals
must be available, and must also be easy to apply by both the payer and the provider
(see payer characteristics, page 25) 67 . With this regard, Conrad and Christianson
(2004) point out that there may be strong differences between perceived and actual
accuracy of the underlying database for the incentive 35 .
Moreover, correct measurement also involves that the provider’s case-mix is taken into
account, using risk adjustment for outcome measures (see provider and patient
characteristics) 67 , 80 , 81 , 82 , 83 . Some P4Q programmes make also use of a procedure
called ‘exception reporting’ 84 . This procedure enables providers to exclude individual
patients from the calculations for specific targets, because there was a valid reason for
not reaching the target in that individual patient, which was not quality of healthcare
related. Exception reporting is mostly restricted to the use of a predefined set of
exclusion criteria as an acceptable rationale. These can include the level of patient
compliance or willingness to cooperate in treatment, the maximal degree of treatment
which can be applied (e.g. when a maximal dose of a drug has been prescribed, without
further alternatives, and still the quality target is not met) and the influence of co
morbidities on the appropriate care in an individual patient (the typical example being
not to provide an eye examination to a diabetes patient who is blind). Procedures like
exception reporting are used as a safeguard to protect professional autonomy and
therapeutic freedom 85 , 86 .
The discussion about exception reporting points our attention to the fact that incentive
schemes always risk generating unintended consequences 87 , 88 . According to Dudley
and Rosenthal (2006) there are three important negative effects to look for: patient
selection, diversion of attention away from other important aspects of care, and
widening gaps in performance among providers. 78