Pay for Quality
Pay for Quality
Pay for Quality
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KCE Reports 118 <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> 61<br />
receiving beta blocker prescription at discharge and the percentage of eligible<br />
congestive heart failure (CHF) patients receiving ACE inhibitor prescriptions at<br />
discharge. The <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> programme was implemented during a 4 year period.<br />
The incentives consisted of add-ons to the DRG reimbursement, with a maximum of<br />
1.2% in 2000-2002, and 2% in 2003. For the interpretation of the economic evaluation a<br />
threshold of $50 000 per QALY was considered. Applying this threshold, the results<br />
seem to suggest cost-effectiveness, even in a worst case scenario. See Table 3.<br />
Table 3 : Cost-effectiveness evaluation of a heart care related programme by<br />
Nahra et al. (2006)<br />
<strong>Quality</strong> indicator Discounted QALYs<br />
(lower bound-upper<br />
bound)<br />
AMI patients receiving aspirin<br />
discharge orders<br />
AMI patients receiving betablocker<br />
discharge orders<br />
CHF patients receiving ACE<br />
inhibitor discharge orders<br />
Incentive<br />
programme costs<br />
53.0 - 67.6 - -<br />
141.6 - 261.3 - -<br />
538.7 - 1372.4 - -<br />
Cost-effectiveness<br />
ratio<br />
Sum of indicators 733.3 - 1701.2 $22 059 383 $30 081/QALY -<br />
$12 967/QALY<br />
4.4.2 Modelling costs or effectiveness<br />
Five modelling articles have been identified, of which three studies are conducted in the<br />
UK 226 , 227 , 228 , and two in the USA 229 . All these models aim at predicting either the<br />
short term financial consequences or the long term health consequences of P4Q<br />
programmes.<br />
Kahn et al. (2006) 229 examine the hospital quality and financial per<strong>for</strong>mance under two<br />
<strong>Pay</strong> <strong>for</strong> <strong>Quality</strong> programmes in the US, namely the Premier Hospital <strong>Quality</strong><br />
Demonstration programme with a duration of 3 years and the Medicare <strong>Pay</strong>ment<br />
Advisory Commission (MedPAC) pay <strong>for</strong> quality programme. Seventeen clinical quality<br />
measures concerning heart attack, heart failure and pneumonia are been taken into<br />
account. Under the premier hospital <strong>Quality</strong> incentive demonstration, hospitals can<br />
receive annually bonuses up to 2% (top ten percent per<strong>for</strong>ming hospitals). Penalties with<br />
a maximum of 2% (hospitals below the 10 th percentile of per<strong>for</strong>mance) are only given in<br />
the third year and the penalty threshold is established in the first year of the<br />
programme. Within the MedPAC P4Q programme hospitals lose 1-2 % of there<br />
payment, to create a pool of funds that can be used to pay bonuses. In both the<br />
programmes only the top 20 percent of best per<strong>for</strong>ming hospitals receive a bonus. The<br />
MedPAC approach would redistribute $140 million in payments, the Premier approach<br />
would almost pay $10 million more than it collects through penalties. See Table 4.<br />
Table 4 : Winners and losers by Hospital type and by <strong>Pay</strong> <strong>for</strong> <strong>Quality</strong><br />
Program (millions of dollars) by Kahn et al. (2006)<br />
Type of hospital Premier pay <strong>for</strong> quality<br />
Medicare <strong>Pay</strong>ment Advisory<br />
Scenario<br />
Commission (MedPAC) pay <strong>for</strong><br />
quality scenario<br />
Total bonus Total penalty Total bonus Total penalty<br />
All hospitals $39.4 -$30.5 $139.8 -$139.8<br />
Urban $34.0 -$25.2 $117.2 -$119.8<br />
Rural $5.3 -$5.1 $21.6 -$18.8<br />
Major teaching $8.3 -$4.3 $26.3 -$21.9<br />
Other teaching $14.3 -$9.4 $50.1 -$51.6<br />
Non teaching $16.6 -$16.8 $62.4 -$65.1<br />
Tax-exempt $32.6 -$20.0 $114.8 -$105.6<br />
Investor-owned $3.0 -$6.3 $10.7 -$17.5<br />
Public $2.7 -$4.1 $14.2 -$16.6