Pay for Quality

26 Pay for Quality KCE Reports 118
Also, in a context of multiple payers, the question about coordinated action from
different payers can be raised. On the one hand, a payer may be reluctant to work
alone if the fruits from the programme are also of benefit for other payers (because the
providers treat patients related to different payers); in other words, one wants to avoid
a free-rider situation in which certain payers profit from the efforts of other payers. On
the other hand, if payers compete with each other, it may be more interesting to obtain
a competitive advantage through P4Q. 78
Although the vision on the health care system and the typology have already been
discussed before (see health care system, page 24) these may also be considered as
payer specific since it obviously possible that a payer has a different vision as compared
to the overall health system, and operates in his specific way (e.g. a private insurer
within a NHS).
3.2.2.3 The provider
The health (care) provider can be considered as the target audience of a P4Q
programme. The provider can be an individual physician (GP or specialist), a group of
physicians, a hospital, a hospital department, a resting home, etc...
As said before, it is of importance that the programme is in line with the provider’s
culture. For instance, the emphasis of Custers et al. (2008) on continuous improvement,
innovation and mutual learning (see above) was believed to fit well with the vision of the
Canadian physicians 75 .
In the following, we will discuss consecutively provider’s motivation, the target unit, and
other organisational aspects.
Motivation
How can providers be motivated to participate in a programme? Motivation of health
professionals is often ignored in P4Q programmes 110 , 111 .
A rather simplistic view on this is that when explicit incentives are used to change
behaviour, the motivating effect of money will channel the professionals to the policy
defined goals.
In this view, each physician has a target income, and incentives that help to achieve that
income will change behaviour. It also means that if the desired income has already been
reached a P4Q programme will have less effect 38 , or that providers whose performance
has improved but does not reach the threshold, could become demotivated to make an
effort 67 .
More importantly, this view ignores the complex interplay of internal and external
factors affecting the health professional’s behaviour 75 , 110 . As social beings and as agents
for their patients, physicians are driven by important societal and professional norms
35, 67
and by altruism, in addition to net income.
Thus, the financial incentive might either enhance intrinsic motivation if it is viewed as
being legitimating the internal or professional norms or reinforcing them; but it may as
well diminish the strength of the intrinsic quality motivators 35 . In other words, an
extrinsic motivation like the use of financial incentives can crowd out the intrinsic
motivation by for example demotivating individual providers, or devaluating their
altruistic motivation.
Motivation is possibly also related with the level of trust the physician has in the payer.
Conrad et al. (2004) therefore cite trust as a key factor influencing the effectiveness of
P4Q programmes 35 .
It eventually comes down to “internalizing” the external regulation 110 , i.e. to make the
incentives instrumentally important for the personal goals. One could also argue that
our systems should more externalize the intrinsic values of medicine, i.e. reward
societal and professional norms.