Pay for Quality

28 Pay for Quality KCE Reports 118
This dual split may create conflicting goals and is often cited as a major obstacle to
effective collaboration. Financial incentives for doctors and hospitals to do the right
things or to do better are often mismatched or even in conflict 114 , 115 . Better alignment
of incentives is one of the expectations in the pay-for-quality world 116 . A possibility is
that the hospital may make a part of the incentive payment available to clinicians
responsible for quality improvements, thereby to motivate their cooperation. An
alternative form of this “gain sharing” can be developed to afford physicians direct
payments as an incentive, not to improve efficiency but to improve overall hospital
quality. Another form of shared gain (or risk) is the bundled payment in which the
physician and hospital are paid together in one lump sum, which then must be divided
among the different specialists participating in the patient’s treatment. Finally some
specific pay-for-quality models compensate physicians for clinical improvement that
require collaboration with hospitals, or reward hospitals for improvements that may
require physicians to collaborate. This kind of compensations encourages the needed
collaboration between hospitals and physicians in joint quality improvement initiatives.
Further research on Hospital-Physician relationships, who are at the centre of several
policy proposals such as pay-for-quality, gains sharing and bundled payments is required
in this regard.
Organisational aspects
Regardless of how the target unit is defined, organisational aspects at the provider’s side
need to be taken into account. When participating in a P4Q programme, providers may
need to create patient registries, use support staff to monitor medical management and
patient compliance with preventive and treatment protocols, and adopt information
technology to improve access to patient data 54 . Hence, there may be little value in
establishing ambitious performance targets based on process or outcome measures if
providers have weak information systems and poor office systems for managing patient
care 78 .
Moreover, there may be costs associated with complying with the programme 75 , and
the response of providers is likely to be influenced by their costs of performing the
tasks necessary to improve. This can be considered in economic terms as an
opportunity cost 38 . Hence, the reward should address these additional costs in the
design. Obviously one should also take into account the possible benefits. This relates
to cost-effectiveness of P4Q and is being discussed later in this report.
Finally, the number of patients in a practice, the quantity of services per patient 35 , 38 , but
also the physician’s age, gender, specialty, years since completion of the training, etc. can
37, 38, 78
influence the compliance of physicians with the guidelines.
3.2.3 The patients
Several patient characteristics can influence the outcomes of a programme 38, 54 . For
instance, age, education level, insurance status, socio-economic status, etc.
Also their awareness of the programme (are patients aware of prices, and financial
aspects of the programme, do patients receive information about the provider’s
behaviour) is of importance. Several authors notice that such disclosures should be
handled carefully to safeguard the patient provider relationship 117 .
Especially the presence of co-morbidities in patients and how this affects best practice
care is of concern to some 118 , 119 . Finally, the patient has through his own behaviour a
large influence on certain P4Q outcome targets. His lifestyle, cooperation and level of
therapeutic compliance will co-determine his health evolution, next to provider action.
A general principle is to safeguard P4Q purposes by assigning accountability only to a
degree that corresponds with clear responsibility and control. Therefore patient
behaviour has to be taken into account 120 .