Pay for Quality

38 Pay for Quality KCE Reports 118
Based on free market competition a number of commercial for profit Health
Maintenance Organizations (HMOs) include P4Q in their insurance packages,
contracting by negotiation with providers as a form of managed care 188 . Only a few
studies report the alignment and integration of different health plans’ strategies 196 .
74 , 172 , 192 , 196 , 197 , 198 , 199 , 200 , 201 ,
Most providers are further organized into medical groups
202 , 203 171 , 183 , 184 , 187 , 198 , 199 , 202 , 203
or independent practice associations (IPAs) . These
organizations often represent hundreds of providers and act as negotiation and
contracting partners with the insurers. In medical groups this goes often further in
terms of clinical healthcare organization and coordination. Besides the network and
group HMO models of managed care, some authors specify indemnity, point of service,
and staff HMO models 204 . The following attributes are assigned to the managed care
models in terms of gate keeping:
• Network HMO (IPAs): healthcare is not covered outside the network
• Group HMO and Staff HMO: healthcare is not covered outside the group
unless recommended
• Point of service: there is a preferred network without imposing restrictions
205
• Indemnity: free choice of healthcare providers 206
Some studies focus on a rural area 177 , an urban area 44 , 180 , 181 , 182 , 184 , or both 171 . Area
representativeness is rarely tested in USA studies for other characteristics, with the
exception of some studies that focus on a more deprived area 145 , 180 , 181 , 182 , 184 , 185 , 195 .
However, provider characteristics are reported upon in more detail. The size can be
large 74 , 145 , 183 , 187 , 189 , 190 , 191 , 193 , 196 , 201 or small 44 , 188 , 195 . Some studies exclude smaller
sites to reach sufficiently large sample sizes 184 . Other use such restrictions on the
medical group/IPA level 172 , 186 , 198 , 199 , 200 , 202 , 207 , 208 . This can lead to a 90-95% exclusion
rate 209 . Ownership can be private 182 , 188 , 197 versus public 210 . Teaching status can be
academic versus non academic 44 , 188 , 195 .
74 , 171 ,
The general payment system is often a mix. In many studies capitation dominates
179 , 183 , 184 , 187 , 188 , 203 175 , 178 , 206
, but sometimes fee for service is dominant . Medical groups
often make use of capitation payment. Indemnity models make more use of fee for
service, but have a low presence in the systematic review sample. Fee for service
providers are excluded in some studies 185 . Salary as a dominant payment system is rare
145
. Diagnosis Related Groups (DRG) based lump sum payment is often a component in
hospital reimbursement 211 .
Often a selection is made in terms of provider in- and exclusion criteria. These criteria
are:
• An ‘active provider’ indicator: providing care to a minimal number of patients
171 184 177 , 178
. Possible thresholds are: 25 patients , 50 patients , 20 hours of
194 , 212
patient care per week
• An ‘active provider’ relative to a specific patient group: providing care to a
minimal number of target patients. Thresholds are: 50 patients per month per
provider 195 , 2500 claims submitted 181 , 15 or more denominator patients 206 ,
at least 30 cases per condition annually 44 , at least 20 patients in each time
span 193 , have 10 target patients continuously enrolled 187 , having at least 200
episodes with 10 patients eligible for a certain measure 69
• A ‘stable patient panel’ indicator: exclusion of rapidly growing practices 177
• An ‘intervention experience’ indicator: inclusion of clinics that had applied the
intervention for four years or longer 210 , been a member physician for at least
24 months 187
• Exclusion of residents and fellows 194
194 ,
• Exclusion of specific specialty groups such as radiologists and pathologists
199 , 202 , 209
• No refusal to cooperate with study procedures 195
• No moving or retiring of the provider involved 195