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