Existing P4Q interventions

Since 2004, quality has been introduced as a major part of the general practitioners remuneration in primary care in the UK. This occurred by means of the implementation of the Quality and Outcome Framework (QOF) in the UK health care system.²³⁶ This framework has been described extensively in chapter 4. Participation in QOF is voluntary, however because of the high incentive, participation is high. Previous schemes, like ‘the good practices allowance’, which was launched in 1986, failed in their objective. At the time the medical culture was characterized by the idea that quality could not be measured and that there is no such thing as ‘a bad doctor’. From that time on, the medical culture has changed in a sense that physicians and government began to recognize that the quality is not as high as we like it to be and that there is some variation between and within countries. High quality programme failures like ‘the Bristol case’, in which the death rate for congenital heart surgery in the Bristol Royal Infirmary was much higher than in other hospitals, was a kind of trigger to change medical culture.

In the UK, P4Q programmes came together with already existing quality initiatives, hence physicians in the UK had already become familiar with quality assessments (for example: audit programmes).

In 1990, there has also been a small P4Q scheme related to the immunization of children and to cervical cytology, targeted at achieving 90% of children and 80% of eligible women respectively. Initially this scheme wasn’t very popular but after a while it was accepted and a larger coverage for these 2 indicators was obtained.

Recently, a pilot P4Q hospital scheme in the north West of England, called ‘advancing quality’^e, has been introduced, which is basically an attempt to replicate the ‘Premier Demonstration project’, a hospital P4Q programme which was implemented in the US (see next paragraph). This scheme is an answer to ‘the next stage review’ report, in which the surgeon lord Darzi, reasserted quality care being the key dimension in terms of where we want health care to go to.

e for more information see the following link http://www.advancingqualitynw.nhs.uk/

6.2.2.2 The United States

For decades, the US is characterized by many different P4Q schemes, using many different initiators (a more extensive description can be found in chapter 4) Consequently P4Q schemes are largely adopted by one payer at a time, although there are several regional multi-payer initiatives. The P4Q concept became popular around the time that the Institute of Medicine released its report ‘Crossing the quality chasm’

that indicated much underuse of Evidence Based Care and in which it was stated that payment systems should recognize quality. Large employers, which are the most important purchasers of private health insurance in the US, found the concept op P4Q appealing. Companies like General Electric and IBM have followed high-reliability manufacturing principles and supply chain principles in their own businesses and they are frequently trying to apply these principles to health care purchasing. Around 2000-2001 some big employers were organizing public reporting initiatives (the leapfrog Group) and others began to get interested in Pay for Quality programmes. Although some health insurance plans picked it up on their own, P4Q implementation in the US would not have happened without the support of the employers.

Many of the P4Q experiments in the US were performed in the private sector.

Nowadays, more than half of managed care insurers, HMOs and PPOs are currently using P4Q schemes. Most state Medicaid programmes are also using P4Q schemes.

Medicare, which is the most important payer in the US, has had a P4Q programme for hospitals, named the Premier demonstration project, based on which experience Medicare has the intention to launch a permanent P4Q hospital programme. According to the US experts there is an extremely weak P4Q programme for physicians, involving voluntary submission of quality data within Medicare.

According to US experts there is a link between P4Q and managed care in the US. In some places where managed care was never important, there is much less of an effort by payers to have any determination over what kind of health care services are delivered. Consequently P4Q schemes haven’t been implemented that much in these places.

Currently there are more than 100 physician targeted programmes and about 40 hospital targeted programmes, most of them run by private health plans. Providers have multiple payers, each with their own P4Q schemes. This fragmentation makes it fuzzy for physicians to distinguish the quality indicators for each P4Q scheme and to modify behaviour accordingly.

In some metropolitan areas that have been dominated by managed care, new initiatives tried to align different P4Q schemes by different payers in one scheme, as for example in the Integrated Healthcare Association^f (IHA) in California. The IHA has taken a lead in coordinating a P4Q programme with the attempt to line up all care, measuring the same thing and rewarding physicians and hospitals more or less in the same way. This has led to a uniform P4Q scheme with only one set of indicators despite all the different payers.²³⁷ The programme is starting to expand the set of measures, not only including effectiveness measures but also efficiency measures.

It must be noted that P4Q is only a part of all the activities that are being used in the US to ‘buy on the basis of quality’. One of the other activities is ‘tiering’, in which patients have to pay less for healthcare delivered by high quality and efficient providers and they have to pay more for healthcare delivered by low quality and inefficient providers.

Likewise some health insurance plans offer ‘narrow networks’: instead of contracting with every physician, purchasers contract with a smaller set of physicians who have demonstrated better performance.

f For more information see the following link http://www.iha.org/

6.2.2.3 Australia

The last 20 to 25 years there has been a desire amongst Commonwealth Government in Australia to reduce the amount of money paid to general practices based on FFS and increase the amount of money that is paid at general practices on another basis than FFS. The government is trying to move away from simply rewarding production.

Regarding the medical services in primary care, there is a Pay for Quality programme named the Practice Incentive Program (PIP), which is organized at a national level and applicable for all accredited general practices.²³⁸ The incentives in the PIP project are paid by the commonwealth government. The incentives in the Queensland project are paid by the state. The government conducted some modelling exercises to make sure there was enough money to pay for the indicators. In both programmes participation is voluntary.

Beside these P4Q programmes, 15 years ago a hospital accreditation programme was introduced in Victoria in which a small supplementary payment was provided. However this payment was not directly linked with quality.

A number of states have incentive programmes regarding waiting lists and waiting times in hospital services. Currently there is only one state (Queensland) that has a real Pay for Quality programme for hospitals (the Clinical Practice Improvement Program^g). This P4Q programme was implemented as a result of a significant quality scandal in 2005 and aims at improving quality. About 16 quality of care indicators are included in the programme. Clinical networks, which are run by clinicians (cardiac network, mental network, etc) were involved in the development of these indicators. A number of health insurance funds have additional requirements on hospitals to undertake patient experience or patient satisfaction surveys, but hospital incentives aren’t directly linked to these indicators.

6.2.2.4 The Netherlands

In the Netherlands P4Q has been initiated by the government. A first P4Q initiative was developed mid 1990’s. General practitioners were paid for influenza immunization of their patients, and for carrying out cervical smears amongst their eligible patients.

Currently three Pay for quality initiatives in primary care can be distinguished in the Netherlands.

1°. The organization of care groups regarding certain disorders (for example diabetic care), in which participants are being paid based on the outcome on quality indicators.

2°. A second initiative is related to a practice accreditation programme of general practitioners. Participation in the programme, which consists of supplying information on clinical indicators, information on the organization of the practice and patients surveys, is being rewarded by a limited allowance. In the first year physicians get an accreditation for participation.

After the first year general practitioners have to establish an improvement programme.

In the second year accreditation can be obtained if physicians have acted according their improvement programme.

3°. A third initiative consists of a bonus programme developed on top of the accreditation programme. In this experiment there are about 75 voluntary health care providers and 2 voluntary private insurers. To start this experiment a restricted set of clinical indicators has been selected, related to 4 chronic diseases, prevention and medication use. Moreover, some patient experience indicators and management indicators are included. All indicators are being evaluated every year, except the management indicators, which are being evaluated every 3 year. The incentives are being paid by the health plans. Participation is voluntary, but this will change. The moment a new payment system will arise, participation will become mandatory.

Currently, it is not clear yet if health plans will work with one coordinated P4Q programme in the future or if each of them will have their own P4Q scheme.

g for more information see the following link http://www.health.qld.gov.au/cpic/

Concerning hospital care, several public reporting initiatives are been implemented.

Currently no P4Q programmes are yet been developed^h. Key points on interventions

UK

• In the past several P4Q schemes have been launched in primary care. These initial P4Q schemes were limited in scope, but likely did improve cervical screening and immunisation rates over time.

• In 2004, QOF has been introduced successfully in primary care. This P4Q programme targets clinical indicators, patient experience and practice organization. Recently a pilot P4Q scheme, called ‘advancing quality’ has been implemented in the North West of England.

USA

• The USA is characterized by its many different P4Q schemes, in primary care as well as in hospital care. Large employers put pressure on private insurers to initiate the first P4Q schemes. Currently, Medicare and more than half of managed care insurers, HMOs and PPOs, are using P4Q

schemes. In California the IHA has successfully introduced a uniform, multi-payer P4Q scheme. P4Q is only one of the activities used in the US to improve quality.

Australia

• Regarding hospital care there is only one P4Q programme, named the Clinical practice improvement programme that is implemented in

Queensland. In primary care the Practice Incentive Program is introduced at national level.

The Netherlands

• Three P4Q programmes in primary care can be distinguished in the

Netherlands. The organization of care groups, the accreditation programme of GPs, and a bonus pilot programme, which is developed on top of the accreditation programme