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> 81<br />
A medical education in the UK is weakly related to better P4Q per<strong>for</strong>mance on the<br />
QOF 147 . One study in the USA reports that physicians trained abroad per<strong>for</strong>m better<br />
144<br />
(W).<br />
On the level of provider organizations most research has been done concerning general<br />
practices, medical groups and independent practice associations. Little results are<br />
known on a hospital level.<br />
One collection of studies has reported on the effect of those distinctions: the difference<br />
between medical group, Independent Practice Association (IPA), hospital and<br />
community based P4Q per<strong>for</strong>mance. Medical groups are likely to per<strong>for</strong>m better than<br />
IPAs (W) 199 , 202 , 209 . Rittenhouse & Robinson (2006) 186 reported that hospital and<br />
community based care per<strong>for</strong>med better than IPA based care (W). The relatively good<br />
per<strong>for</strong>mance of medical groups or networks of medical groups is also confirmed by<br />
Mehrotra et al (2007) 200 (W).<br />
A positive relationship is reported <strong>for</strong> the age of the group or the age of the<br />
organization 202 , 208 (W).<br />
In the USA, ownership of the organization by a hospital or health plan is positively<br />
related to P4Q per<strong>for</strong>mance, as compared to individual provider ownership (W)<br />
198 , 199 ,<br />
202 , 207 , 208 , 209<br />
. Practice ownership by a provider is associated with incentives to increase<br />
services (W) 212 . Full ownership of groups is associated both with incentives to increase<br />
some and to reduce other services. One study found only <strong>for</strong> preventive care a positive<br />
association with an organization being profitable and P4Q results (W) 186 . Bhattacharyya<br />
et al (2008) 211 found no relationship with the size of revenues (W). Some of these<br />
authors point to the difference in available resources <strong>for</strong> investment purposes as part of<br />
a possible explanation.<br />
The teaching status of a hospital is positively related to P4Q per<strong>for</strong>mance 211 (W).<br />
Geographical location is sometimes also positively related to P4Q results (W). This is<br />
illustrated by two studies finding an association with a location in the Midwestern USA<br />
and in Cali<strong>for</strong>nia as compared to other USA regions 199 , 211 . There is no difference in<br />
per<strong>for</strong>mance between rural, urban and mixed areas 132 (W).<br />
There is conflicting evidence concerning the influence of the size of the organization in<br />
terms of number of providers and number of patients (C). Some studies report a<br />
positive relationship between the number of patients and P4Q per<strong>for</strong>mance (W)<br />
95 , 131,<br />
140 , 153 , 208 , 209 , 211 183 142 , 177<br />
. Others report no relationship or a negative relationship (W).<br />
There is a small negative relationship with the practice population size (W) 147 . Practices<br />
with a large patient population are also more likely to exception report more patients<br />
(W) 84 . The size of a hospital is not related to P4Q results (W) 211 .<br />
Group practices per<strong>for</strong>m better on P4Q than single handed practices according to some<br />
studies 132 , 177 , 183 and the other way around according to other studies 195 (C). Mehrotra<br />
et al (2007) 200 found a positive relationship with having more than the median number<br />
of physicians available. Other studies came to similar results 198 , 199 , 202 , 207 (W). Sutton &<br />
McLean (2006) 136 found a similar positive relationship <strong>for</strong> the size of the team and the<br />
non principal proportion of the team (recently trained) (W). Ashworth et al (2005) 140<br />
found this kind of relationship <strong>for</strong> the size of staff budgets (W).<br />
A smaller practice size is also related to other factors such as having patients with<br />
poorer health, being located in a deprived area, having more patients from minority<br />
ethnic groups, etc. 137 (W). These interrelationships have to be taken into account when<br />
assessing the practice size characteristic and its P4Q effects. The complexity of such<br />
relationships is also illustrated by McLean et al (2007) 129 who mapped factors related to<br />
remoteness of the practice area.<br />
Tahrani et al (2008) 166 report that the per<strong>for</strong>mance gap between large versus small<br />
practices which existed be<strong>for</strong>e QOF implementation has disappeared afterwards (W).