Pay for Quality

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60 Pay for Quality KCE Reports 118 Table 1 : Cost-effectiveness evaluation of 12 QOF indicators by Mason et al. (2008) Quality indicator Incremental QALYs per patient AF3: treatment with anticoagulant drug therapy or an antiplatelet drug therapy BP5: hypertension, BP 150/90 in past 5 months Incremental costs per Net monetary patient treated (2006) benefit per patient treated (2006) treated (2006)* 1.465 to 2.2 -£1 162 to -£16 922 £45 162 to £46 222 0.7 £751 £13 249 CHD9: aspirin 0.0066 -£30 £162 CHD 10: beta blocker 1.89 £234 £37 566 CHD 11: ACE inhibitor/ Angiotensin Receptor Blocker 0.08 £488 £1 112 ChKD4: ACE inhibitor/ Angiotensin Receptor Blocker 0.8076 to 1.5308 -£31 811 to -£32 906 £49 058 to £62 427 CS1: Cervical screening 0.137 £68 £2 672 DM15: proteinuria / microalbuminuria on ACE 0.7210 -£9 662 £24 081 DM21: diabetic retinal screening 0.4865 £9 750 -£21 LVD/HF3: ACE inhibitor/ Angiotensin Receptor Blocker 0.21 £25 £4175 Smoking 2: Smoking advice/referral 0.0157 to 0.0451 £11 to £90 £303 to £812 Stroke9/stroke12: antiplatelet/anticoagulant 0.17 £371 £3 029 * The net monetary benefit is calculated by assigning a value of £20,000 for each QALY gained. Curtin et al. (2006) 225 focus on the cost-effectiveness of a pay for quality programme in primary care in the USA, directed at physician organizations, and focusing specifically on diabetic care. Between 2000 and 2004 a partnership was established between a Health Plan and a physician organization. The physician organization withholds 10 percent of claims payments to practitioners of which typically 70 percent to 100 percent is available for distribution at the end of the year. Additional dollars derived from gainsharing programmes were added to the pool. Payment in the Pay for Quality programme varied from 50 to 150 percent, as a result from which an average full-time primary care physician could earn between $6 000 and $18 000 extra in a given year, based on performance. The return on investment calculation, included in this study makes use of a cost trend, to project costs and compare the projected cost with the actual cost. As a result the actual costs seem to be lower than the projected cost. As shown in Table 2, this resulted in a plan saving of $1 894 470 in year 1 (2003) and $2 923 760 in year 2 (2004). The annual system development costs were estimated at $1 150 000. As a result the return on investment estimate would be 1.6 to 2.5. Table 2 : Return on investment evaluation of a diabetes quality improvement programme by Curtin et al. (2006) Plan savings diabetes Total cost per year of Return on care against two-year rolling trend the programme investment Year 1 $1 894 470 $1 150 000 1.6:1 Year 2 $2 923 760 $1 150 000 2.5:1 Nahra et al. (2006) 107 evaluated the cost-effectiveness of hospital Pay for Quality incentives in the USA, focusing on heart care related hospital inpatient care. The pay for quality programme has been implemented in 85 hospitals and provides incentives to increase adherence to heart-care related clinical guidelines. Three process measures for heart care discharge have been considered, namely the percentage of eligible AMI patients receiving aspirin orders at discharge, the percentage of eligible AMI patients
KCE Reports 118 Pay for Quality 61 receiving beta blocker prescription at discharge and the percentage of eligible congestive heart failure (CHF) patients receiving ACE inhibitor prescriptions at discharge. The Pay for Quality programme was implemented during a 4 year period. The incentives consisted of add-ons to the DRG reimbursement, with a maximum of 1.2% in 2000-2002, and 2% in 2003. For the interpretation of the economic evaluation a threshold of $50 000 per QALY was considered. Applying this threshold, the results seem to suggest cost-effectiveness, even in a worst case scenario. See Table 3. Table 3 : Cost-effectiveness evaluation of a heart care related programme by Nahra et al. (2006) Quality indicator Discounted QALYs (lower bound-upper bound) AMI patients receiving aspirin discharge orders AMI patients receiving betablocker discharge orders CHF patients receiving ACE inhibitor discharge orders Incentive programme costs 53.0 - 67.6 - - 141.6 - 261.3 - - 538.7 - 1372.4 - - Cost-effectiveness ratio Sum of indicators 733.3 - 1701.2 $22 059 383 $30 081/QALY - $12 967/QALY 4.4.2 Modelling costs or effectiveness Five modelling articles have been identified, of which three studies are conducted in the UK 226 , 227 , 228 , and two in the USA 229 . All these models aim at predicting either the short term financial consequences or the long term health consequences of P4Q programmes. Kahn et al. (2006) 229 examine the hospital quality and financial performance under two Pay for Quality programmes in the US, namely the Premier Hospital Quality Demonstration programme with a duration of 3 years and the Medicare Payment Advisory Commission (MedPAC) pay for quality programme. Seventeen clinical quality measures concerning heart attack, heart failure and pneumonia are been taken into account. Under the premier hospital Quality incentive demonstration, hospitals can receive annually bonuses up to 2% (top ten percent performing hospitals). Penalties with a maximum of 2% (hospitals below the 10 th percentile of performance) are only given in the third year and the penalty threshold is established in the first year of the programme. Within the MedPAC P4Q programme hospitals lose 1-2 % of there payment, to create a pool of funds that can be used to pay bonuses. In both the programmes only the top 20 percent of best performing hospitals receive a bonus. The MedPAC approach would redistribute $140 million in payments, the Premier approach would almost pay $10 million more than it collects through penalties. See Table 4. Table 4 : Winners and losers by Hospital type and by Pay for Quality Program (millions of dollars) by Kahn et al. (2006) Type of hospital Premier pay for quality Medicare Payment Advisory Scenario Commission (MedPAC) pay for quality scenario Total bonus Total penalty Total bonus Total penalty All hospitals $39.4 -$30.5 $139.8 -$139.8 Urban $34.0 -$25.2 $117.2 -$119.8 Rural $5.3 -$5.1 $21.6 -$18.8 Major teaching $8.3 -$4.3 $26.3 -$21.9 Other teaching $14.3 -$9.4 $50.1 -$51.6 Non teaching $16.6 -$16.8 $62.4 -$65.1 Tax-exempt $32.6 -$20.0 $114.8 -$105.6 Investor-owned $3.0 -$6.3 $10.7 -$17.5 Public $2.7 -$4.1 $14.2 -$16.6
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Pay for Quality

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