Pay for Quality

30 Pay for Quality KCE Reports 118
Communication
According to Rosenthal (2008), earlier P4Q efforts are perceived to have had too little
impact on provider behaviour 69 . The way the payer communicates with the provider
may therefore be crucial in the success of a programme (see agency theory and
provider motivation). Young et al. (2005) cite different communication approaches such
as local and regional meetings, hardcopy and electronic mailings, and websites 54 .
Several theories focus on effective communication aimed at changing individual attitudes
and behaviours 121 . For instance, the Persuasion-Communication Model presents a
stepwise model of persuasion: exposure to a message, attention to that message,
comprehension of the arguments and conclusions, acceptance of the arguments,
retention of the content, and attitude change (McGuire 1985 122 , in Grol et al, 2007 121 ).
A critical step in any P4Q programme is to involve providers early so that they can help
payers to identify performance indicators or measurement systems that meet providers’
standards for validity and by facilitating cooperative relations needed to maintain
provider participation 78 . This also involves a planned negotiation process between
payers and providers 35 .
Yet, it is questioned in the literature to which extent the providers should be aware of
all the details and subtleties of the programme. Perhaps, if the programme is addressed
to an organisation or to a group of physicians (see target unit, page 27), the “leader” of
that organisation or group needs to be aware of all these subtleties, but not the
individual practitioner. On the other hand, one may argue that a programme designed
without the active participation of all participants and without their strong
understanding of the nature and the rationale of the changes is bound to fail (see
motivation, page 26).
Identify sources of data to perform the evaluation
Learning about the impact of a P4Q programme can be particularly challenging because
a multitude of additional forces simultaneously affect the quality of patient care and
costs 78 . Therefore in any P4Q programme, the availability of correct data for evaluating
the performance of providers is of crucial importance. These data must be reliable and
integer, in order to allow correct evaluation and to install feed-back processes regarding
the achievement of the targets 54 .
Also, some care regarding the design of the evaluation process is needed to disentangle
the effects of the programme from other trends. At a minimum, payers should collect
baseline data on the targeted quality measures 78 .
Particularly for the hospital context, two important requirements need to be met in
order to allow for a P4Q programme related to avoiding in-hospital complications 95 , 123 .
the ability to distinguish diagnoses that are present at admission from diagnoses that
develop post admission, and the ability to identify diagnoses that represent
complications that are potentially preventable.
An essential part of evaluation is the evaluation of the programme itself: the validation
of the programme (did it meet its overall objectives according to the planned process);
the sustainability of the realised changes; and the financial impact and return on
investment. As we will see in the next chapters, few papers have already tackled the
latter issue: is investing in P4Q programmes potentially cost-effective, and under which
circumstances? This involves a regular review of processes and content. Note thereby
that cost-effective does not necessary means that the investment in the P4Q
programme is completely recuperated by savings in the system. It may be that there is
still a net cost (a net investment) which is then to be balanced with the health gain.