3 A THEORETICAL FRAMEWORK FOR P4Q
3.4 P4Q PRINCIPLES FOR DESIGN AND IMPLEMENTATION
In this section, a multifactorial implementation framework (see Figure 2) is proposed that can be applied by designers of a new P4Q programme. The ‘MIMIQ’ model (Model for Implementing and Monitoring Incentives for Quality), which can also be interpreted as a checklist, is generally applicable, and contains different items which are not necessarily to be considered as mandatory elements of a P4Q programme, but rather as aspects to keep in mind and to challenge when designing a programme.
The framework is in our view comprehensive and complementary to previously published models/checklists. For instance, Dudley and Rosenthal (2006) published a checklist focussing on the content of P4Q programmes 78.
They distinguished 4 phases, thereby setting the basis for a time dimension in the design and implementation of P4Q: the contemplation phase, the design, the implementation and the evaluation. Based on other conceptual models identified in our review, we build further on this phased approach in our checklist. Figure shows how we made a distinction between questions related to the context and actors (health care system, payers, providers, patients) on the one hand and the programme on the other hand.
Finally, the interplay between both creates the full P4Q picture.
Later in this report we will come back to this model on different occasions, since based on the existing evidence of what works and what doesn’t (chapter 4) it will become more clear to which extent the different elements of the model need to be complied with in order to increase the chances for a successful programme.
Figure 2 : P4Q conceptual implementation framework: Model for Implementing and Monitoring Incentives for Quality (MIMIQ)
Medical leadership, role of peers, role of industry Existence/implementation of guidelines, room for improvement
Level of own control on changes
Target unit (individual, group/organisation, …) and size In case of not-individual, size of unit (# providers)
Role of the meso level (principal or agent) Demographics (age, gender, specialty,…) Organisational resources and information systems Organisational system change and extra cost/time required
Number of patients and services per patient Payer characteristics Type of system (e.g. insurance or NHS)
Level of Competition
Decentralisation of decision making and therapeutic freedom Dominant payment system (FFS, salary, capitation, ...) Quality
Different (7) possible Quality dimensions Structure, process, and/or outcome indicators
Number of targets and indicators SMART targets
Relative or absolute (competitive or not) Stable and long enough Simplicity and directness
Communicating the program Communication to whom (providers, patients, ...)
Detail and terminology of the communication Quality of the communication Financial impact and return on investment Implementing the program
Involvement of providers in setting goals Mandatory or voluntary participation Staged approach of implementation Stand alone/embedded in broader quality project
Key points
• P4Q programmes are intended to offer explicit financial incentives to
providers in order to achieve predefined quality targets. Quality goes further than the strict clinical outcome. It includes 7 dimensions: safety, clinical effectiveness, patient centeredness, timeliness, equity of care, efficiency of care and continuous and integrative careb. Furthermore quality can be expressed in structural, process and outcome quality criteria. Many P4Q programmes focus mainly on structure and process outcomes. However, given the scarcely grounded relationship between process measures and long term patient outcome measures, overly relying on structure and process outcomes threatens the credibility of a P4Q programme. As important as the choice of criteria is the final number of criteria. Too few criteria could draw the attention of providers away from the not
incentivized criteria. Too many criteria could lead to organisational complexity. When setting these criteria, it is important to verify that the criteria are measurable. A valid and comprehensive management
information system to track performance against the goals must be available. Correct measurement makes use of risk adjustment. Some P4Q programmes make use of exception reporting. Gaming, patient selection and diversion of attention are the most important types of unintended consequences.
• Financial incentives are considered as the core of a P4Q programme.
Several possible incentives structures are possible: bonuses, performance based fee schedule, performance based withholds, regular payment increase linked to performance and quality grants/financial awards/performance funds. There is still some disagreement amongst researchers about whether bonuses or penalties should be applied. Most programmes make use of bonuses whereby ideally, an incentive size should amount up to 5% of income and according to some authors even up to 10% of income. The formulation of the incentive arrangement is of importance. Rewarding a threshold could discourage low-quality providers to engage in the P4Q programme. P4Q programmes often provide payment only on one or a few fixed time points. Some P4Q programmes attach payment weights to specific quality targets as a function of the estimated related workload, or to express the relative importance of a target in terms of public health. Some P4Q programmes make use of an absolute reward whereby anyone who performs well obtains the reward no matter how the other providers perform. Other P4Q programmes use a ‘tournament approach’, where providers compete against one another. The latter method has the advantage that the expenses are more under control, however the uncertainty about what can be achieved could provoke providers not to engage in the programme. Finally, a balance should be found between the simplicity of the programme on the one hand and sufficient attention for all the issues related to P4Q complexity on the other hand.
• Health care, payer, provider and patient characteristics are the main contextual factors and are of influence in various ways. Not taking these factors into account will compromise the success of a possible P4Q programme.
• Several market and environmental characteristics, like the private/public mix, the dominant payment system, the level of competition and the level of therapeutic freedom among providers, can drive quality, and thus P4Q success.
b Quality on a global level also involves reducing variability in care
• The principal agent theory broadly addresses relationships in which both parties have different abilities, in which there is asymmetric information and in which the parties have different goals. Related to a P4Q programme, the
“agent” (the health care provider) can be both a potential ally and a potential source of resistance to P4Q.
• The use of clinical guidelines in current policies, variable patient
contributions, other quality programmes, the availability of management information systems, the number of payers, the accuracy of the data system, the vision of the payer regarding health care goals and the typology
(private/public/regional/…) are important mechanisms that influence the way a payer can and will implement P4Q.
• Internal and external motivational drivers, the specifically targeted “unit”
(an individual or a group) and organizational aspects are of importance in the behaviour of health care providers.
• Finally, patient demographics, co-morbidities, their socio-economic and insurance status, information about price and quality and several patient behavioural patterns influence the outcome of P4Q programmes.
• When planning the introduction of a P4Q programme, all relevant concepts and contextual factors have to be understood and taken into account.
Furthermore, when introducing P4Q, money has to be made available, either new money or by disinvestments elsewhere or planned savings within the programme. A stepwise introduction (phasing), permits testing the targets and indicators, gives the providers the chance to gear up for a P4Q initiative and enables purchasers to evaluate the small scale impact before applying it to the larger group. The way of communicating the programme to the providers is seen as crucial in the success of the programme. The evaluation of the programme itself is as important as communication and implementation.