Pay for Quality

KCE Reports 118 Pay for Quality 45
There is no limit on the number of patients whom family practitioners may exclude,
although the physicians’ decisions may be questioned at annual inspection visits by
Primary Care Trusts, which are NHS organizations with managerial responsibility for
primary care in geographic areas that contain up to 100 practices.
Family practitioners already had some experience with financial incentives from the
limited use of incentive programmes for cervical cytological testing (i.e. Papanicolaou)
and immunization that were initiated in 1990. This preceding P4Q system is evaluated
by some of the included studies 125 , 132 , 140 , 177 . A second incentive that was introduced in
the 1990 contract provided generous remuneration for family practitioners to establish
“health promotion clinics” to encourage preventive screening and lifestyle interventions.
Some evaluation studies are available 153 . The incentives schemes can be seen as a
precursor of the current QOF scheme. The problems experienced with gaming and
data manipulation in those early years are countered as much as possible in the new
incentives system by the use of a thorough audit process, with peer participation, and
severe penalties whenever fraud is discovered. All included UK studies concern the
latest QOF contract as described above unless they are explicitly referenced for the
1990 contract. Most authors omit a detailed description of P4Q as studied intervention.
Hospital care
Since the first of October 2008, the NHS has launched a demonstration project
concerning P4Q in hospital care. The programme, called ‘Advancing Quality’, which is
implemented in the North West region of the UK, makes use of incentives based on
three types of targets: evidence based process measures, patients’ quality of life after
surgery and the patient’s experience of provided care. The programme is supported by
peer review and public reporting. Because the first evaluation results of this project are
expected to be available in 2010, this project is not included in this review of primary
P4Q evaluation studies.
4.2.4.2 United States of America
The characteristics of P4Q as intervention in the USA are very diverse, as is the case
for the contextual characteristics. Almost all described studies concern bonus systems.
Similar to the UK QOF programme most USA programmes make use of thresholds
(e.g. 20 up to 90%) to be met in terms of the percentage of patients eligible for a certain
indicator. In most studies this figure represents the level of targeted achievement in
patient number with indicator met (the higher thresholds) or the level of targeted
improvement in patient number with indicator met (the lower thresholds).
The indicators used are of a structural, process and/or outcome measure nature.
Whenever patient outcome measures are used, these are mostly intermediate measures
instead of long term outcome measures (e.g. the tracking of HbA1c levels instead of the
tracking of long term diabetes complications).
The size of the incentive varies:
• A fixed amount, e.g. $5 144 , $50 195 , $50-80 69 , $100 220 , $750-1 250 193 ,
$1 000-5 000 181 , $1 000-7 500 182 , $5 000-10 000 201 .
• A certain percentage of the providers’ or provider organization yearly
revenues, e.g. 0-5.5% 205 , 0-7% 188 , 0.8% 74 , 0.5-1% 190 , 1-2% 44 , 174 , 175 , 176 , 211 ,
2.2% 172 , 1-7.5% 206 , 4% 221 , 5% 187 , 10% 171 , 177 , 178 , 183 , 184 , 12% 222 171 , 177 ,
or 20%
178 , 183 , 184 , 189 , 191 .
• Use of a bonus pool with a floor and ceiling amount 197 , use of a maximum i.e.
one bonus procedure per encounter 144 .
Only a few authors report on programmes that base the incentive amount on the level
of estimated savings due to quality improvement 69 .
The base for incentive calculation and the target level vary between programmes. The
base for calculation can be (sometimes combined):
• An incentive as a percentage of capitation per patient eligible 69 , 183 , 184 .
• An incentive per patient with target met 74 , 177 .