Pay for Quality

KCE Reports 118 Pay for Quality 37
Wales has a stronger focus on public health and local partnerships. In Northern Ireland,
no major reforms have recently been conducted 130 .
These regions are further divided into a number of strategic health authorities, each
responsible for a primary care sub region. Many studies are conducted at this level to
define their study scope in terms of region and population. A number of UK studies
explicitly focus on an urban area 126 , 138, 140 , 149 , 150 , 151 , 153 , 154 , 155 , 156 , 157 , 158 , 161 , others on a
rural area 129 , or both 153 , 165 . In the other UK studies this characteristic is not reported.
Some studies investigate P4Q in a more socio-economical deprived area
125 , 136, 149 , 150 , 153
, 154 , 155 , 156 , 157 , 158 , 161 126
, while others are conducted in a more affluent area . Some
authors explicitly state that the study region and population is nationally representative
in terms of these characteristics. Other UK studies do not report on these
characteristics. Similar comparisons are made in terms of ethnicity
150 , 154 , 155 , 156 , 157 , 158 ,
161 136, 150 , 154 , 155 , 156 , 157 , 158
and population age distribution of the study area as a whole .
A few authors report the level of representativeness of the study area characteristics
for the whole health system under consideration 151 , 158 . The dominant payment system
for UK general practitioners is capitation (based on the number of patients, adjusted for
characteristics of the patients and the area such as deprivation level).
The following providers were the focus in UK studies:
• General practitioners are the main target group, at a general practice level.
Only a few authors include other provider specialties such as community
child health doctors when describing the pre QOF (Quality and Outcomes
Framework) P4Q schemes 132 . See section 4.2.4.1 (page 43) for more
information on QOF.
• Inclusion of providers is often based on data availability in national or regional
clinical databases using automatic data extraction from electronic patient
records.
• Only a few UK studies exclude practices based on additional criteria such as a
minimal yearly number of patients per practice, missing disease registries,
84 , 130 , 139 , 142 , 148 , 167,
practice relocation, and change in practice population size
169 .
4.2.2.2 United States of America
The market, payer and provider characteristics in P4Q evaluation studies in the USA
are very heterogeneous. Providers have multiple payers, private as well as public. Each
of these is involved in purchasing health care resulting in about 300 health insurance
plans. The dominant payment system in the US often is a mix, but Fee For Service (FFS)
is the most often used for physician services.
Some studies focus on a privately insured population 69 , 170 , 171 , 172 , others on a publicly
insured population 173 , often provided by Medicare for more socio economically
deprived patients 44 , 95 , 174 , 175 , 176 , 177 , 178 , 179 . P4Q evaluation studies that focus on
Medicaid were also included 145 , 180 , 181 , 182 , 183 , 184 , 185 , 186 . Only a few studies describe for
which percentage of patients of an included provider or provider organization a health
plan accounts 74 , 171 , 187 .
The P4Q programmes in the USA were directed at primary care and, to a more limited
extent, at hospital care (see Appendix 15). Some programmes include both primary and
hospital care. This can be a regional provider network 145 , 188 or an integrated healthcare
delivery network 189 , 190 , 191 , 192 , 193 .
Primary care in USA studies is often defined more broadly than in non USA studies. In
addition to family physicians, many studies also include paediatricians
171 , 172 , 173 , 181 , 184 ,
194 , specialists in internal medicine 69 , 170 , 171 , 172 , 194 , 195 or geriatricians 194 as primary care
providers. Only a few studies specify whether solo 181 , 187 , group or both types 178 of
practices are included.
Healthcare insurance and payment are, in addition to Centers for Medicare & Medicaid
Services (CMS), mostly organized on a regional or local level, with a diversity of forms
and systems.