Pay for Quality

40 Pay for Quality KCE Reports 118
Key points on contextual aspects
United Kingdom
• In the UK, P4Q is implemented in a national NHS regulated healthcare
system, focusing on primary care.
• Market and payer characteristics include uniformity of the system and the
payment scheme, universal health insurance, low competition, absence of
gate keeping, free care at the point of access and case mix adjusted
capitation as the general GP payment system.
• P4Q is arranged by a national contracting approach with participation of
providers at the practice level.
• Many studies focus on the differences of care between urban and/or deprived
regions in the UK.
• Inclusion of providers in studies is based on data availability within the
national electronic data extraction system. Exclusion of providers in the
studies is limited.
USA
• Contextual characteristics in the USA are very heterogeneous.
• Insurance is based on a public-private mix, with non-universal coverage.
Health Maintenance Organizations (HMO) and Preferred Provider
Organizations (PPO) contract with providers on a more regional or local
level from a managed care approach. Gate keeping is present to a varying
degree.
• Providers are often organized into medical groups or IPAs. Any provider’s
payment is based on multiple schemes from different health plans. The
general payment system consists of a large part of fee for service, although
capitation and fixed payment use is growing. This contrasts with the
relatively high number of studies focusing on capitation based healthcare
delivery. There is a high level of competition between professionals.
• P4Q in the US is diversely implemented in both primary and hospital care
settings. Primary care is more broadly defined in the US than in most
European countries, i.e. outpatient care in hospitals is considered as primary
care.
• US studies focus less on area and population characteristics compared to the
UK, but more on provider characteristics such as the size of an organization,
ownership, teaching status and payment components.
• Provider selection criteria used in studies consist of indicators such as
providers’ activity level, panel size and stability. Because P4Q is organized
on various levels in the USA, patient attribution to providers based on
responsibility, is sometimes unclear. This is in contrast with the UK where
patients are assigned to a certain physician who is responsible for the wellbeing
of his patients.
Australia, the Netherlands, Germany, Italy and Spain
• One Australian study focused on public hospitals’ emergency departments,
the other on family day care in a community setting.
• One German study focused on general practitioners.
• One Italian study focused on public maternity hospitals and immunization
clinics in a NHS environment.
• The Spanish study involved primary care teams of physicians and nurses. No
further details are provided on these characteristics.