Pay for Quality

46 Pay for Quality KCE Reports 118
• An incentive per intervention as incentivized quality indicator, e.g. per
vaccination 144, 177 , 178 , 179 , 180 , 181 , 182 , 196 .
• An incentive per composite measure level. The composite measure is the
44 ,
aggregation of separate indicator measures into one overarching measure
174 , 175 , 176 , 193 , 206 , 211 , 222 , 223 .
• An incentive amount according to the number of providers per clinic 201 .
• An incentive based on the DRG based hospital payment amount
221 .
44 , 174 , 176 , 211 ,
• An incentive based on an all-or-none target performance 189 , 193 .
The target level can be:
• The individual provider level 69 , 177 , 180 , 182 , 187 , 193 .
• The practice or organization level 172 , 183 , 184 , 188 , 196 , 201 , 210 , the physician
organization or medical group level 74 , 197 , 203 44 , 174 , 176 , 211 ,
, the hospital level
221 .
• The team level of per patient responsible individual providers combined
205 , 206 .
• Some authors direct the incentive at the different levels of a network 191 .
• The supervisors’ level 223 .
In addition to additional bonus approaches, many USA systems competition and
redistribution between providers or organizations based on their quality performance 44
, 174 , 175 , 176 , 187 , 188 , 191 , 211
.
This implies in most cases the use of a bonus and withholds combination, imposing
reward and punishment. In a few cases it concerns a bonus given to the best performing
providers, without a withhold or punishment at the other end 183 , 205 , 206 .
P4Q in the USA is sometimes directly combined with explicit incentives aimed at
productivity, utilization management and/or cost containment 69 , 144, 171 , 188 , 212 .
A minority of USA P4Q programmes provides an incentive based on the level of
181 , 183 ,
improvement through time instead of or combined with a fixed threshold level
184
. This longitudinal approach uses combinations of multiple thresholds for one
indicator linked to the incentive amount 223 . For example, the bonus amount goes up
gradually as a function of reaching a 20%, 40%…100% threshold.
Exception reporting is used rarely in the evaluated USA P4Q programmes. One study
uses it as a goal for reduction in the context of clinical pathway use 171 . The concept and
approach differs from the UK QOF approach of exception reporting.
The frequency of related quality measurements and the timing of the incentive provision
vary. The most common frequencies include a yearly rate 170 , 188 , 195 , 210 , 222 , a semi-annual
rate 183 , 184 , 193 , a four month interval rate 181 , 182 , a quarterly rate 74 , 195 177 ,
, a weekly rate
178
. Only a few authors describe the degree of time delays between healthcare provision,
data collection, feedback (if present) and incentive payment. This can vary from no delay
up to six months of delay 74 .
Feedback and P4Q payment do not always occur within the same time frame. It is for
example possible to provide monthly feedback and award an incentive each six months
193
.
Most authors do not discuss the differential weighting of targets to be met, with some
exceptions 197 . In most cases this implies the use of an equal weighting system, although
this is not always clear.
Although sometimes stated in early P4Q literature, only a few authors indicate that the
proprietary nature of the P4Q schedule prohibits a detailed description 170 .
171 ,