Pay for Quality

KCE Reports 118 Pay for Quality 21
The principal type of unintended consequence is patient selection or more generally
“gaming”, where participants find ways to maximize the measured results without
actually accomplishing the desired objectives 75 . Diversion of attention has been earlier
described as the risk associated with multitasking (see above for quality targets) 89 .
Widening gaps in performance may be the result of differences in motivation and
response to the programme (which are in turn influenced by the type of incentive,
communication etc. - see also further) and should therefore be systematically
monitored. At present there is no evidence supporting these effects 90 .
3.1.2 Incentives
3.1.2.1 Introduction
Incentives are part of everyday life in all its aspects. People do things for various reasons
both of a non financial and a financial nature. A drive to act, behave, change, etc. in a
professional context is related to personal work satisfaction, to recognition and status
and to receiving financial and non financial resources and opportunities in exchange for
professional healthcare delivery (the effort) and performance (the results of the effort)
a
. There is a wealth of evidence available that financial incentives have an impact on
professional behaviour, both in healthcare as in other sectors 92 . The, often unconscious
and not deliberate, effect of financial incentives can impact behaviour both in a positive
as in a negative way 93 .
Whereas some financial incentives have always been used in the history of healthcare or
have been introduced to maintain or improve target performance (salary, fee for
service, capitation,…) 94 , a P4Q programme does the same but is explicitly aimed at
quality of care. New innovative forms of payment approaches are emerging rapidly 69 .
The actual incentive is often considered as the core of the programme, since the overall
aim of a P4Q programme could be considered as a better alignment of the incentives of
providers with the health system goals 75 . To be clear, in this context, incentives are
considered to be explicit (and not broad categories of “incentives” such as fee for
service, salaries or capitation) 35 . In this paragraph, we focus on the possible structure
and magnitude of this explicit incentive. 38
3.1.2.2 Incentive structure
38 , 54 , 75
The following different possible incentive structures can be considered:
• Bonuses, rewarding providers with additional payments for achieving the
stipulated targets. This has been a popular approach in many programmes,
likely because of its relative attractiveness towards providers. Yet, while such
bonuses may be effective, they are not necessarily cost-effective. 75 Related to
bonuses is the so called “pay for activities”, whereby the merely presence of
required activities (without a result commitment) is rewarded. Also related
to bonuses are the so-called “shared savings contracts”, whereby the goal of
the programme is in the first place to save money and whereby the provider
is then entitled to receive a share of the realized savings.
• Performance based fee-schedule; the only difference with bonuses, is that the
payment is ongoing rather than one-time or periodic. Mark-ups to a usual fee
35, 38
(also called enhanced fee for service) are an example of this.
• Performance based withholds; since it has been shown that individuals place
more value on losses than on equivalent gains, withholds or financial penalties
may be more effective than bonuses. 78 Also, as Averill et al. (2006) state,
paying bonuses comes down to rewarding what in fact should be standard of
78, 95-97
care.
• The empirical evidence with regard to the effect of penalties is however
limited, as will be shown in Chapter 4. 78
a Examples of the Global Health Workforce Alliance are provided in their guidelines report. 91