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> 37<br />
Wales has a stronger focus on public health and local partnerships. In Northern Ireland,<br />
no major re<strong>for</strong>ms have recently been conducted 130 .<br />
These regions are further divided into a number of strategic health authorities, each<br />
responsible <strong>for</strong> a primary care sub region. Many studies are conducted at this level to<br />
define their study scope in terms of region and population. A number of UK studies<br />
explicitly focus on an urban area 126 , 138, 140 , 149 , 150 , 151 , 153 , 154 , 155 , 156 , 157 , 158 , 161 , others on a<br />
rural area 129 , or both 153 , 165 . In the other UK studies this characteristic is not reported.<br />
Some studies investigate P4Q in a more socio-economical deprived area<br />
125 , 136, 149 , 150 , 153<br />
, 154 , 155 , 156 , 157 , 158 , 161 126<br />
, while others are conducted in a more affluent area . Some<br />
authors explicitly state that the study region and population is nationally representative<br />
in terms of these characteristics. Other UK studies do not report on these<br />
characteristics. Similar comparisons are made in terms of ethnicity<br />
150 , 154 , 155 , 156 , 157 , 158 ,<br />
161 136, 150 , 154 , 155 , 156 , 157 , 158<br />
and population age distribution of the study area as a whole .<br />
A few authors report the level of representativeness of the study area characteristics<br />
<strong>for</strong> the whole health system under consideration 151 , 158 . The dominant payment system<br />
<strong>for</strong> UK general practitioners is capitation (based on the number of patients, adjusted <strong>for</strong><br />
characteristics of the patients and the area such as deprivation level).<br />
The following providers were the focus in UK studies:<br />
• General practitioners are the main target group, at a general practice level.<br />
Only a few authors include other provider specialties such as community<br />
child health doctors when describing the pre QOF (<strong>Quality</strong> and Outcomes<br />
Framework) P4Q schemes 132 . See section 4.2.4.1 (page 43) <strong>for</strong> more<br />
in<strong>for</strong>mation on QOF.<br />
• Inclusion of providers is often based on data availability in national or regional<br />
clinical databases using automatic data extraction from electronic patient<br />
records.<br />
• Only a few UK studies exclude practices based on additional criteria such as a<br />
minimal yearly number of patients per practice, missing disease registries,<br />
84 , 130 , 139 , 142 , 148 , 167,<br />
practice relocation, and change in practice population size<br />
169 .<br />
4.2.2.2 United States of America<br />
The market, payer and provider characteristics in P4Q evaluation studies in the USA<br />
are very heterogeneous. Providers have multiple payers, private as well as public. Each<br />
of these is involved in purchasing health care resulting in about 300 health insurance<br />
plans. The dominant payment system in the US often is a mix, but Fee For Service (FFS)<br />
is the most often used <strong>for</strong> physician services.<br />
Some studies focus on a privately insured population 69 , 170 , 171 , 172 , others on a publicly<br />
insured population 173 , often provided by Medicare <strong>for</strong> more socio economically<br />
deprived patients 44 , 95 , 174 , 175 , 176 , 177 , 178 , 179 . P4Q evaluation studies that focus on<br />
Medicaid were also included 145 , 180 , 181 , 182 , 183 , 184 , 185 , 186 . Only a few studies describe <strong>for</strong><br />
which percentage of patients of an included provider or provider organization a health<br />
plan accounts 74 , 171 , 187 .<br />
The P4Q programmes in the USA were directed at primary care and, to a more limited<br />
extent, at hospital care (see Appendix 15). Some programmes include both primary and<br />
hospital care. This can be a regional provider network 145 , 188 or an integrated healthcare<br />
delivery network 189 , 190 , 191 , 192 , 193 .<br />
Primary care in USA studies is often defined more broadly than in non USA studies. In<br />
addition to family physicians, many studies also include paediatricians<br />
171 , 172 , 173 , 181 , 184 ,<br />
194 , specialists in internal medicine 69 , 170 , 171 , 172 , 194 , 195 or geriatricians 194 as primary care<br />
providers. Only a few studies specify whether solo 181 , 187 , group or both types 178 of<br />
practices are included.<br />
Healthcare insurance and payment are, in addition to Centers <strong>for</strong> Medicare & Medicaid<br />
Services (CMS), mostly organized on a regional or local level, with a diversity of <strong>for</strong>ms<br />
and systems.