Pay for Quality

78 Pay for Quality KCE Reports 118
These worries were described in the USA situation and to a much lesser extent in the
UK situation. Only one programme in the USA, the Integrated Healthcare Association
(IHA) directed programme in California, is known for its alignment of different payers in
how P4Q is developed and implemented.
The conceptual framework predicted that the dominant payment system would be of
influence on P4Q results. One study found a small significant positive relationship of
capitation with P4Q results 198 . Another study came to similar findings 173 . Since both
studies concern early generation P4Q schemes with a large focus on cost containment
and utilization management, these findings should be treated with caution (see also
Pourat et al, 2005). Sutton & McLean (2006) 136 found in a UK study a negative
association between the level of capitation payment and P4Q performance. Rittenhouse
and Robinson (2006) 186 reported that a lower percentage of capitation was significantly
related to more care management processes use for preventive care.
The first results do not conform to the conceptual framework expectations, the latter
do (C). It should be noted that UK results for P4Q are in general positive, with the use
of capitation as a general payment scheme combined, whereas USA results, often
combined with Fee For Service, are more variable. Again we emphasize that many other
variables act as concurrent mediators, which might cloud theoretically expected
relationships.
With regard to the influence of the degree of competition between providers one study
reports that higher perceived competition for attracting patients is positively related to
both incentives to increase services as to incentives to decrease services (W) 212 . This
seems to correspond with the distinction between underuse and overuse corrective
targets. Because this study originates from the USA with an environment with high
patient volatility and high levels of public reporting (consumer driven healthcare), these
results might not be readily transferrable to other country healthcare systems.
Figure 6: P4Q context: Health care system characteristics
Health care system characteristics
Values of the system:
Lack of reporting on the level of congruence (N)
No negative effect of combining clinical quality with efficiency goals (W)
Type of system (e.g. insurance or NHS):
Independent of the identification of P4Q initiators and coordinators, uniformity of
P4Q design is important (S)
Level of Competition:
Lack of evidence on how the general level of competition in the health care
system influences P4Q (N). A lower patient volatility is assumed to support P4Q
on the one hand. P4Q and consumer driven care might reinforce each other on
the other hand.
Decentralisation of decision making:
Centralized decision making supports uniformity, the avoidance of incentive size
dilution, transparency and awareness (S). However, this should be combined with
local priority setting based on room for improvement (S).
Dominant payment system (FFS, salary, capitation, ...):
Conflicting evidence, best use of theoretical guidance (C)