Pay for Quality

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32 Pay for Quality KCE Reports 118 Figure 2 : P4Q conceptual implementation framework: Model for Implementing and Monitoring Incentives for Quality (MIMIQ) Payer characteristics Mission/vision of the payer Typology (private/public/mixed) Current use of clinical guidelines Variable patient contribution Other incentive programs running Availability of information systems Number of payers Accuracy of information system Quality Different (7) possible Quality dimensions Structure, process, and/or outcome indicators Number of targets and indicators SMART targets Quality measurement Case-mix Exception reporting Unintended consequences Communicating the program Communication to whom (providers, patients, ...) Detail and terminology of the communication Quality of the communication Targeted or widespread communication Implementing the program Involvement of providers in setting goals Mandatory or voluntary participation Staged approach of implementation Stand alone/embedded in broader quality project Provider characteristics Awareness, perception, familiarity, agreement, self-efficacy Other motivational drivers Medical leadership, role of peers, role of industry Existence/implementation of guidelines, room for improvement Level of own control on changes Target unit (individual, group/organisation, …) and size In case of not-individual, size of unit (# providers) Role of the meso level (principal or agent) Demographics (age, gender, specialty,…) Organisational resources and information systems Organisational system change and extra cost/time required Number of patients and services per patient Health care system characteristics Values of the system Type of system (e.g. insurance or NHS) Level of Competition Decentralisation of decision making and therapeutic freedom Dominant payment system (FFS, salary, capitation, ...) Incentives Incentive structure Threshold value and/or improvement Weight of different quality targets Size Frequency Relative or absolute (competitive or not) Stable and long enough Simplicity and directness Evaluation of the program Sustainability of change Validation of the program Review and revising the process Financial impact and return on investment Patient characteristics Demographics, Co-morbidities Socio-economics, Insurance status Information about price and/or quality Patient behavioural patterns (cultural and consumer patterns, compliance)
KCE Reports 118 Pay for Quality 33 Key points • P4Q programmes are intended to offer explicit financial incentives to providers in order to achieve predefined quality targets. Quality goes further than the strict clinical outcome. It includes 7 dimensions: safety, clinical effectiveness, patient centeredness, timeliness, equity of care, efficiency of care and continuous and integrative care b . Furthermore quality can be expressed in structural, process and outcome quality criteria. Many P4Q programmes focus mainly on structure and process outcomes. However, given the scarcely grounded relationship between process measures and long term patient outcome measures, overly relying on structure and process outcomes threatens the credibility of a P4Q programme. As important as the choice of criteria is the final number of criteria. Too few criteria could draw the attention of providers away from the not incentivized criteria. Too many criteria could lead to organisational complexity. When setting these criteria, it is important to verify that the criteria are measurable. A valid and comprehensive management information system to track performance against the goals must be available. Correct measurement makes use of risk adjustment. Some P4Q programmes make use of exception reporting. Gaming, patient selection and diversion of attention are the most important types of unintended consequences. • Financial incentives are considered as the core of a P4Q programme. Several possible incentives structures are possible: bonuses, performance based fee schedule, performance based withholds, regular payment increase linked to performance and quality grants/financial awards/performance funds. There is still some disagreement amongst researchers about whether bonuses or penalties should be applied. Most programmes make use of bonuses whereby ideally, an incentive size should amount up to 5% of income and according to some authors even up to 10% of income. The formulation of the incentive arrangement is of importance. Rewarding a threshold could discourage low-quality providers to engage in the P4Q programme. P4Q programmes often provide payment only on one or a few fixed time points. Some P4Q programmes attach payment weights to specific quality targets as a function of the estimated related workload, or to express the relative importance of a target in terms of public health. Some P4Q programmes make use of an absolute reward whereby anyone who performs well obtains the reward no matter how the other providers perform. Other P4Q programmes use a ‘tournament approach’, where providers compete against one another. The latter method has the advantage that the expenses are more under control, however the uncertainty about what can be achieved could provoke providers not to engage in the programme. Finally, a balance should be found between the simplicity of the programme on the one hand and sufficient attention for all the issues related to P4Q complexity on the other hand. • Health care, payer, provider and patient characteristics are the main contextual factors and are of influence in various ways. Not taking these factors into account will compromise the success of a possible P4Q programme. • Several market and environmental characteristics, like the private/public mix, the dominant payment system, the level of competition and the level of therapeutic freedom among providers, can drive quality, and thus P4Q success. b Quality on a global level also involves reducing variability in care
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Pay for Quality

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