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