Pay for Quality

KCE Reports 118 Pay for Quality 27
Also, the role of medical leadership in supporting the P4Q programme (as one of the
many roles that medical leadership fulfils) is described by Conrad et al. (2004) as
potentially influencing motivation and therefore effectiveness of P4Q programmes 35 .
Finally, the practicing physician’s knowledge and understanding will contribute to the
motivation to act in line with the goals 35 , 38, 54 .
The latter is immediately related with the level of involvement of the individual clinicians
and their degree of autonomy. Here again, it could be argued that more involvement
and more autonomy will increase motivation.
Note that Conrad et al. (2004) also refer to peers’ knowledge of individual provider
performance, as a variable potentially influencing effectiveness of P4Q programmes.
Indeed, if peers are aware of the performance of an individual physician, this will
definitely influence his/her behaviour 35 .
According to Adams and Hicks (2001), the industry can have an important role in
affecting physician professional behaviour 112 . The incentives given by pharmaceutical
representatives to providers can effect providers prescribing and professional behaviour
113
.
The role of the media in P4Q programmes is rather small. However in public reporting,
where the quality of care provided by physicians or hospitals is made publicly, the media
plays an important role. The availability of ranking lists or performance reports on the
internet can influence physicians’ behaviour 38 .
The target unit
Another important question is related to the “target unit” , i.e. to whom to address the
incentive.
According to Dudley and Rosenthal (2006) 3 factors determine the choice of the unit:
1° Where the largest benefit can be achieved; 2° the share of covered services
delivered by the providers (providers treating rare diseases are in this view less
interesting targets); and 3° available performance measures and existing data for each
type of provider. 78
A related question is whether the programme should be focussed on a manager of a
department, an individual clinician, or a department or group of physicians 67 .
Most studies on P4Q have not distinguished between the effects of incentives that
target the physician organisation and those that target the individual physician.
Targeting incentives at the individual provider makes the accountability clearer and
implies that the target provider is more in control of his actions.
Targeting incentives at the medical group or hospital system level can also be beneficial
because it can encourage collaboration, coordination and interaction. Also, if the
performance measurement system is subject to some variation, this variation is
expected to be averaged out 78 . On the other hand, the free-rider phenomenon may
occur here as well when targeting provider groups 35 .
An automatic question that then rises is what the role of the “meso” level will be (e.g.
the head of department): will this meso level play the role of a principal or of an agent
67
? Referring back to the agency theory, definition of the principal and the agent requires
careful consideration. Suppose that in a P4Q programme, hospitals are the target
audience (hence the agent): the incentive payments go to the hospital for performance
according to the standards of the principal. To successfully improve quality of delivered
care, the hospital as an agent must rely on the cooperation of their medical staff and
other clinical people, who are often not employees of the hospital 107 .
Physicians enjoy a monopoly in several major decision areas: the decision to admit
patients to the hospital, the decision to perform procedures, the decision regarding
which procedure to perform, and the decision to prescribe pharmaceuticals. This
professional autonomy is reinforced in a fragmented financing system, paying physicians
on a fee-for-service basis and hospitals on a prospective payment basis.