Pay for Quality

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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 .
KCE Reports 118 Pay for Quality 29 3.3 IMPLEMENTING AND COMMUNICATING THE PROGRAM In this paragraph, we discuss, largely based on the above knowledge, which steps are to be involved when initiating a P4Q programme, and which elements require special attention in that process. Importantly, these steps should be considered in the context of a quality circle, whereby the measurement phase leads to adjusting the goals, design and implementation. Understand the concepts and the context A logic requirement when planning the introduction of a P4Q programme is to understand all the above after carefully considering all relevant mediators and reaching consensus in terms of the choices and options which have to be assessed and decided upon. Specifically for a semi-decentralized system like Belgium this means that the political context within which a possible programme is implemented must be clarified (responsibilities of the federal and the regional health authorities) Making money available Obviously, introducing a P4Q programme implies that money is made available. Potential sources of funds for a P4Q initiative include (see Dudley and Rosenthal 2006 78 , and see above -incentives): • New money • Redirection of existing money • Reallocation of payment among providers, e.g., through a combined bonuspenalty payment scheme. • Cost savings resulting from improved quality. • The latter seems to be sometimes wrongly conceived as a necessary consequence of P4Q programmes (see for instance Young et al, 2005 54 ). Yet, improving quality is not necessarily associated with net savings. Stepwise introduction Payers introducing a P4Q programme may consider a stepwise introduction, also called phasing 78 . Advantages for phasing in P4Q are that it permits testing of measures before full scale implementation, giving providers time to gear up for a P4Q initiative; and enables purchasers to evaluate the small scale impact before applying it to the larger group of providers. Options for phasing in P4Q include the following: • Pilot test a payment scheme in a limited geographic area. • Focus on specific provider types or clinical areas. • Begin with pre-existing, national target sets and add targets over time. • Rely on existing data (most likely billing data) and incorporate additional data as needed over time. • Begin with a voluntary system. • Begin with (private) quality reports and introduce incentives over time. • Begin with a modest benchmark for performance and raise the standard over time. • Begin with requiring or rewarding data collection and reporting and introduce performance incentives over time.
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Pay for Quality

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