Pay for Quality

KCE Reports 118 Pay for Quality 23
On theoretical grounds it can be stated that behaviour and consequences should be
related in time as closely as possible. However, a continuous preoccupation with the
incentive effects would also divert attention of providing care on a regular daily basis
without an excessive additional programme related workload. The costs of a continuous
reporting and payment system are likely to exceed the benefits due to time related gain
in quality improvement. Therefore, like in other sectors, P4Q programmes often
provide payment only on one or a few fixed time points such as at the end of the year.
This also gives providers a sufficient amount of time to invest in intermediate quality
improvement in between quality measurements. A related question is whether the
incentive is stable and long enough 67 . Incentives which are given on predefined time
points with a sufficient duration over time would offer the providers the assurance that
their efforts in achieving the indicators, will be warranted 67 .
What is the weight allocated to the different dimensions of quality and to the different
criteria within each dimension 35 ? Some P4Q programmes, like the Quality and
Outcome Framework (QOF) in the UK, attach payment weights to specific quality
targets as a function of the estimated related workload or time investment necessary to
affect the targets. The weights can also express other criteria like the relative
importance of specific targets in terms of public health. The QOF example also uses
another weighting approach, based on the distinction of a clinical and organizational
domain. The clinical domain contains process and intermediate outcome targets. The
organizational domain contains a set of structural targets. An extreme form is the
expectation that a provider should perform perfectly on all included quality targets. This
is translated in some programmes into an all-or-none approach, meaning that the P4Q
incentive is only provided if all targets have been met 99 , 100 .
Is the reward relative or absolute? In case of an absolute reward, anyone who performs
well obtains this reward no matter how the others perform. If the reward is relative,
providers compete against one another to obtain a bigger share of the available money.
This is also called the “tournament approach”. The tournament approach has some
theoretical advantages: it is cheaper or at least the expenses are more under control,
and there is also a continuous incentive (to outperform the others). 78 Disadvantages
may include the uncertainty about what can be achieved, so that providers may judge
investments in quality improvement to be unacceptably risky, and decide not to engage
in the programme. 78 The choice between both options is related to what are considered
to be the defining aspects of the level of performance to be achieved. It is easy to state
that the percentage of HbA1c