Pay for Quality

KCE Reports 118 Pay for Quality 77
Figure 5: P4Q concepts: Implementation, communication and evaluation of
the programme
Implementing and communicating the programme
Involvement of providers in setting goals:
Lacking and conflicting evidence, best use of theoretical guidance (C, N)
Communication to whom (providers, patients, ...):
High importance of provider communication and awareness (S)
Mandatory or voluntary participation:
Conflicting evidence, best use of theoretical guidance (C), No evidence of
selection bias in terms of performance history due to voluntary participation
(W)
Staged approach of implementation:
Modelling and piloting can prevent unexpected budgetary effects (S)
Detail and terminology of the communication
Evidence Based communication
Targeted or widespread communication:
High importance of direct and intensive provider communication (S)
Stand alone P4Q programme or embedded in a broader quality project:
A bundled approach reinforces the P4Q effects (S) and serves as a recognition
of the full spectrum of non financial quality improvement initiatives
Evaluation of the programme
Quality Measurement: see paragraph on quality
Sustainability of change:
Target performance does not regress while being incentivized (S),
There is an upper limit on target specific quality improvement (S),
Lack of evidence on post P4Q target performance (N)
Validation of the programme:
Evaluation is confirmed in peer reviewed literature (S),
Lack of evidence on the use of evaluation in programmes with absent or
elsewhere reporting (N)
Review and revising the process:
Too early stage and/or insufficient use of continuous iterative quality
improvement cycles
Financial impact and return on investment: see cost effectiveness results
5.1.6 Health care system characteristics
Congruence with the health system values was present in most P4Q programmes
although the ethical question whether breastfeeding should be incentivized using
negative incentives for providers not increasing this rate, as was the case in the Italian
study, serves as one example of a potential exception. In the studied schemes, P4Q as
such is focused specifically on clinical effectiveness (as mentioned above). Only a few
USA studies combined this with explicit efficiency related incentives, without a
remarkable difference in results with regard to the other quality domains (W).
A national level of P4Q decision making leads to more uniform P4Q results, as
illustrated by the UK example in contrast with USA initiatives, which show more
diverse forms of experimenting and innovation (S). This affects many of the previously
described central elements such as the level of incentive dilution, the level of incentive
awareness and communication, etc.