DISCUSSION AND CONCLUSION

6.4.1 Key recommendations for design and implementation

To successfully implement a P4Q programme, peculiarities of health system need to be taken into account. The context in which P4Q is being introduced is very different in different parts of the world, so this makes it hard to generalize. The experts suggested the following recommendations for a country at the first initial stage of considering the implementation of P4Q:

Quality goals and targets

1. Be clear about what the priorities and objectives are. It is important to consider which domains to include in the P4Q system: it should be feasible, payable, and lead to better quality. For example financial incentives may be not appropriate in the patient safety domain This domain is probably best covered by for instance critical incident analysis, when things went wrong 2. Indicators should be derived from evidence based criteria and the health care

providers should be included in setting the indicators. Chose indicators where there is still room for improvement;

3. Include different quality domains in the P4Q programme: effectiveness, deprivation measures, timeliness, cost-effectiveness

4. Do not only focus on underuse but also on overuse in health care;

5. Include a sufficient amount of measures. To few measures can lead to

“teaching to the task” (physicians only focus on incentivized indicators and ignore the unincentivized indicators);

6. Strive to include process parameters with a clear and proven link with outcome;

7. Organisational indicators are of limited value although some could be important, e.g. if one is aware of problem areas with major problems, e.g. it is impossible for disabled people to get access to surgeries because they are only to reach by means of the staircase;

8. Measure unintended consequences.

Quality measurement

1. Establish an audit system;

2. No one has ever suggested that clinical guidelines should relate to all patients, so allow for an exception reporting mechanism like in the UK;

3. If possible, make use of available data collection systems to measure quality.

An unnecessary increase in administration workload should be avoided.

P4Q incentives

1. The ideal incentive size should range between 5% and 25%, although it seems that some P4Q programmes with a small incentive can also induce a striking effect;

2. Find a balance between rewarding high achievement and rewarding improvement (There is an argument that payment should be related to improvement, that would give more incentives to low scoring practices);

Implementing and communicating the programme

1. It is important that government and clinical leadership recognize that quality is variable and improvement is important;

2. Include government/ insurers as well as the health care providers and academics from the start in the negotiation process to implement a P4Q programme;

3. Invest in IT development and make data collection automatically. This makes participation less time consuming and it makes gaming more difficult. P4Q can be seen as an opportunity to promote the use of IT and electronic health records;

4. Make use of a phased approach. For example start in a certain region, start with a limited set of indicators or implement an adaption year in which participation is being remunerated;

5. Allocate a well defined amount of money to the development and implementation of a P4Q programme;

6. Make sure that health care providers who will be subject of P4Q have adequate information about their own performance and adequate support for quality improvement;

Evaluation of the programme

1. Examine unintended consequences and think about how schemes could be developed to maintain/improve equity;

2. Measure your baseline first (in the UK, the first targets were easily reached because baseline wasn’t measured properly. This caused the government financial embarrassment).

Health care system and payer characteristics

1. Try to create a uniform P4Q system which is applicable for all physicians (not like in the US with its diversity of schemes and the payer fragmentation problem, where physicians often don’t know what targets should be achieved in which programme);

2. It is important to recognize that P4Q is not a magic bullet. P4Q programmes could have some value it they are organised in the right way, however, these programmes should be seen as part of a range of quality improvement initiatives.

Provider characteristics

1. Incentives should be targeted at the provider unit or the practice group.

Incentives that are given on a higher level could create a moral hazard problem.

Patient characteristics

1. Monitor the effect on unintended consequences concerning patient characteristics.

6.4.2 What the future holds

All experts are convinced that P4Q will continue to exist in their country. The Australian and Dutch experts think that P4Q in their country, which is currently still in a starting phase, will gain importance.

They all agree it is important to attach research to the introduction of P4Q schemes.

On the whole the UK experience, in terms of a modest improvement in quality, is probably consistent with US experience and other countries’ experiences, but ongoing evaluation is necessary on the following items:

• There is a need for research on the optimal size of the incentives and whether a bonus or a withhold or a combination is desired, on the level to which incentives are paid (individual, group, organisation) and on rewarding high achievement or rewarding improvement to improve care and to reduce variation;

• There are still some questions about impact on patient experiences. It is advised by the experts to focus more on patients and less on providers;

• It is important to do more research on unintended consequences, risk adjustment, exception reporting and equity;

• The development of new sets of indicators is an ongoing process (process as well as intermediate outcome measures);

• It is unsure what the effect of P4Q will be in the future. More research on the permanent impact of P4Q on quality should be carried out;

• In most P4Q programmes more quality measures focused on primary care (e.g. vaccination target, cervical smear target, diabetes targets) and less on specialty care. It is a methodological challenge to develop specialty care indicators for specialist and hospital care.

6.4.3 Conclusions

Most recommendations made by the experts are consistent with the ones resulting from the evidence (see 4.4.3 Revising the conceptual framework based on evidence).

Only a few additional issues were cited by the experts. They agree that before considering implementing P4Q programmes, the government as well as clinical leadership should recognize the importance of quality and the variability of quality between physicians. Later on, all stakeholders (insurers, government, health care providers, and academics) should be included from the start in the negotiation process of implementing P4Q. Furthermore the expert draw the attention on the fact that indicators should be derived from evidence based criteria and that quality should be targeted on those indicators that show a lack of quality. In addition, the providers have to be involved in setting the indicators. The experts advise to strive to include process parameters that have a clear and proven link with outcome. When setting the indicators, not only underuse but also overuse should be targeted. Finally it is important toe recognize that P4Q should be seen as one of many different quality initiatives, only a combination of initiatives could lead to a quality improvement in the health care system of a certain country or region.

Overall conclusion by the experts on quality improvement is that financial incentives are modestly effective. Experts agree that P4Q programmes are no magic bullets, however they can be of value, when organised in the right way. These programmes should be seen as part of a range of quality improvement initiatives. Before developing a P4Q scheme it is important to stipulate those areas where quality improvement is desirable.

Physicians should be involved in the developing process and in setting the indicators.

Experts agree that it would be wise to make use of a phased approach.

For collecting the P4Q data it would be advantageous to invest in IT development and to make use of a system in which data are extracted automatically. Despite the fact that until now, there hasn’t been any evidence on unintended consequences, experts agree that further investigation into unintended consequences is desirable. Concerning the indicators, experts suggest finding a balance between rewarding high achievement on quality indicators and rewarding improvement. The ideal incentive should range between 5 and 25%. An incentive that is too high could provoke gaming effects; an incentive that is too low on the other hand could limit the impact in terms of quality improvement. Finally it may be advantageous to create a uniform system, in which indicators are the same for all physicians

Key points on discussion and conclusion

• The following most important recommendations are made by the experts:

be clear about what the priorities and objectives are, include all stakeholders in the negotiation process, invest in IT development and make data

collection automatic, make use of a phased approach, find a balance

between rewarding high achievement and rewarding improvement, examine unintended consequences, develop other quality improvement initiatives to complement P4Q schemes

• All experts agree that P4Q programmes can be of value when organised in the right way. They are convinced that P4Q will gain on importance in the future but they all agree that ongoing evaluation is necessary.