Pay for Quality

More documents

Recommendations

Info

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 .
KCE Reports 118 Pay for Quality 75 Figure 4 : P4Q concepts: Incentives Incentives Incentive structure: Lack of evidence on diverse options, best use of theoretical guidance (N) Threshold value and/or improvement: In both a larger effect size for initially low performers (S) Weight of different quality targets: Weighting according to target specific workload and according to sets of target types (S), Conflicting evidence on composite or all or none measures (C) Size (net additional income achievable): Conflicting evidence, best use of theoretical guidance (C) Frequency: Conflicting evidence, best use of theoretical guidance (C) Relative or absolute (competitive or not): Conflicting evidence, best use of theoretical guidance (C) Stable and long enough: Lack of evidence due to current P4Q initiation phase (N) Simplicity and directness: No apparent negative effect of back office complexity, when combined with front office simplicity (S) 5.1.4 Implementing and communicating the programme Making new money available to fund a P4Q programme shows positive P4Q effects (for example in the UK), while other options show in general more mixed effects (S). However, as the cost effectiveness results indicate, in long term always adding additional funding is no option. Again, a dynamical approach is possible: adding already planned new funding with the use of an innovative P4Q design as a first step and keeping this percentage of the budget as a stable P4Q resource in the following budget periods (see the QOF in the UK). However, as the QOF also illustrates, accurate simulation and planning of the necessary P4Q resources in advance may prevent unpleasant surprises in terms of budget equilibrium. The competitive option, mainly used in the US, shows mixed effects (C). Balancing the resources with estimated cost savings is studied only in one study 69 , with positive results (S). In the UK, there was no stepwise introduction of P4Q. This has led to the need to make a number of corrections afterwards on a national scale. In the other countries demonstration projects have been used (or are ongoing) before considering national implementation. As suggested by the framework this phasing was based on geographical area, provider type, using pre-existing measure sets, etc. Some programmes made use of pay for reporting as a first step. For the USA and other countries it is at present too early to tell whether the lessons learned in such a phased approach leads to a higher positive impact of P4Q as a result.
Page 1 and 2:
Voordelen, nadelen en haalbaarheid
Page 3 and 4:
Voordelen, nadelen en haalbaarheid
Page 5 and 6:
Externe validatoren : Simpson (Univ
Page 7 and 8:
KCE Reports 118A Pay for Quality ii
Page 9 and 10:
KCE Reports 118A Pay for Quality iv
Page 11 and 12:
KCE Reports 118A Pay for Quality vi
Page 13 and 14:
KCE Reports 118A Pay for Quality vi
Page 15 and 16:
KCE Reports 118 Pay for Quality 1 S
Page 17 and 18:
KCE Reports 118 Pay for Quality 3 9
Page 19 and 20:
KCE Reports 118 Pay for Quality 5 W
Page 21 and 22:
KCE Reports 118 Pay for Quality 7 S
Page 23 and 24:
KCE Reports 118 Pay for Quality 9 2
Page 25 and 26:
KCE Reports 118 Pay for Quality 11
Page 27 and 28:
Page 29 and 30:
Page 31 and 32:
Page 33 and 34:
Page 35 and 36:
Page 37 and 38: KCE Reports 118 Pay for Quality 23
Page 77 and 78: Clinical domain (disease) KCE Repor
Page 87: KCE Reports 118 Pay for Quality 73
Page 139 and 140:
Page 141 and 142:
Page 143 and 144:
Page 145 and 146:
Page 147 and 148:
Page 149 and 150:
Page 151 and 152:
Page 153 and 154:
Page 155 and 156:
Page 157 and 158:
Page 159 and 160:
Page 161 and 162:
Page 163 and 164:
Page 165 and 166:
Page 167 and 168:
Page 169 and 170:
Page 171 and 172:
Page 173 and 174:
Page 175 and 176:
Page 177 and 178:
Page 179 and 180:
Page 181 and 182:
Page 183 and 184:
Page 185 and 186:
Page 187 and 188:
Page 189 and 190:
Page 191:
Page 194 and 195:
Wettelijk depot : D/2008/10.273/50
Page 196 and 197:
37. HTA Magnetische Resonantie Beel
Page 198:
108. Tiotropium in de behandeling v
show all

Pay for Quality

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?