Pay for Quality

74 Pay for Quality KCE Reports 118
5.1.3 P4Q incentives
Incentives of a purely positive nature (financial rewards) seem to have generated more
positive effects than incentive schemes using a competitive approach (in which there are
winners and losers), although this relationship is not for all indicators straightforward
(C). This may have impacted the acute hospital care results found in the USA based
Premier demonstration project, which showed an absence of result in the majority of
targets in multiple included studies for myocardial infarction, pneumonia and heart
failure.
The use of a fixed threshold versus a more continuous scale to capture best performers
versus best improvers are both options that gave way to positive results in some
studies and absence of any effect in others (C). What is clear however, and reported in
various studies, is that the positive effect was much higher for initially low performers as
compared to initially already high performers (S). This was the case using each of both
options. This corresponds with the above mentioned room for improvement.
At present the included studies do not enable to make a further distinction on the
effects of different incentive structures (bonus, fee schedule, withhold, regular payment
increases, and quality grants). The algorithm presented by Custers et al (2008) 75
remains untested.
There is no clear relationship between incentive size and the reported P4Q results (C).
Some results comply with logical expectations: QOF results are in general more
positive (size of 20 to 30% of income) and the reported Premier Demonstration project
results are in general of a lower or absent effect size (incentive size of 1 to 2% of
income). But other studies show the opposite direction of relationship, such as both
studies of Hillman and colleagues finding no significant effects (1998, 1999) 183 , 184 with
an incentive size of 20% and the study by Coleman et al (2007a) 144 finding large effects
with a fixed amount of $5 as incentive. Several authors of evaluation studies in the USA
indicate that a diluting effect of the incentive size, due to payer fragmentation, is likely
to have impacted the P4Q results.
A similar incongruence can be found for determining the appropriate frequency of
measurement and payment, which is the next item of the conceptual framework (C).
Both studies with a very short time interval (weekly) 177 , 178 and with a long time interval
(yearly) 170 , 222 show positive results. Studies finding an absence of effect made more use
of quarterly and semi annual rates 74 , 183 , 184 , 195 , but many studies finding positive effects
also used these rates.
There is an absence of evidence with regard to the choice between direct income
stimuli and quality improvement investment stimuli, due to a lack of programmes and
studies including the second option. The QOF, which led to mainly positive effects, is
based on a combination of both. Practices receive a bonus as part of their operational
revenues and can use it to reinforce the practice resources, tools and infrastructure
and/or to allocate additional income to individual physicians.
The effect of simplicity versus complexity of the P4Q programme as such is difficult to
assess, based on the included studies. Having a sufficient number of targets seems to be
of importance, as already mentioned above. Contrary to theoretical expectations the
complexity of the QOF in the UK shows no apparent negative effect on P4Q results (S).
Both the approaches of using composite measures and/or all-or-none measures show
mixed evidence (C), but the absence of effect in some of the related studies is likely to
be related to other framework items such as incentive size, competitive nature of the
programme and the use of long term outcome measures 174 , 175 , 189 , 206 .