Aspectos relevantes

111. Pay-for performance schemes (P4P) have been introduced in several OECD countries. In such

schemes, third-party payers offer financial incentives (bonuses) to providers in exchange for the achievement of agreed quality-of-care targets. These targets generally pertain to preventive care (i.e. percentage of patients vaccinated or screened for defined programmes) or to the management of chronic diseases, such as asthma and diabetes (Maynard, 2008; Bras and Duhamel, 2008; Rosenthal et al., 2006). 112. A set of question (Q34, Q35, Q36 and Q38) investigated the existence and scope of bonuses paid to physicians and hospitals for quality outcomes, as well as positive or negative incentives for complying with good practice guidelines. Countries were invited to provide data on the percentage of physicians receiving bonuses and the share of bonuses in physicians’ revenues, but only a few countries provided the requested information (see Table 17).

113. Twelve countries reported the existence of bonuses for primary care physicians without systematically providing further information on the type of performance targets. Bonuses are linked to quality targets in preventive care and in the management of chronic diseases in seven countries. For instance, 80% of primary care physicians in Poland and in the Czech Republic receive bonuses, which represent 5% of their revenue. In Belgium, 90% of primary care physicians receive bonuses representing 2% of their revenues for the management of chronic diseases. In the United Kingdom, 99% of primary care physicians receive bonuses, which total 15% of their revenue for quality targets linked to prevention, chronic disease management and patient satisfaction. Some countries (New Zealand, Portugal) mentioned that primary care organisations (and not individual providers) are eligible to receive bonuses. In Australia, the Practice Incentives Program (PIP) provides general practitioners with incentives relating to specific activities such as immunisation of children and pap smears for women between the ages of 20 and 69 years who have not had a cervical smear in the previous four years11_.

11. For more details about the Practice Incentive scheme, see

Table 17. Performance-related payment incentives (Q34, Q35, Q36 &Q38) Country Q34. Bonus for primary care physicians Q34. If so, targets related to: Q35. Bonus for specialists Q35. If so, targets related to: Q38. Bonus for hospitals Q38. If so, targets related to: Q36. Penalties if volum e targets exceeded

Australia Yes Preventive care, _{Chronic disease} No No Yes, reduction in _{physicians' fees}(1)

Austria No No No Yes, reduction in physicians' fees Belgium Yes Chronic disease Yes Chronic disease Yes No

Canada No No No Yes, reduction in physicians' fees Czech Republic Yes Preventive care Yes No

Yes, refund to health insurance funds

Denmark No No No Yes, reduction in physicians' fees Finland No No No Yes, refund to health insurance funds France No No No No Germany No No No No Greece No No No No Hungary Yes No No No Iceland No No No No Ireland No No No No Italy Yes Preventive care,

Chronic disease No No

Yes, refund to health insurance funds

Japan Yes Preventive care, Chronic disease Yes

Preventive care,

Chronic disease Yes Clinical outcome No

Korea No No No Yes, reduction in physicians' fees Luxembourg No No Yes No

Mexico No No No No Netherlands No No No No New Zealand Yes Preventive care,

Chronic disease No No No Norw ay No No No No Poland Yes Preventive care,

Chronic disease Yes

Preventive care,

Chronic disease No No Portugal Yes Preventive care,

Chronic disease No No No Slovak Republic No Yes Yes

Clinical outcome, Process, Patient satisfaction, Patient experience

No

Spain Yes Preventive care,

Chronic disease Yes No No Sw eden n.a. n.a. n.a. No

Sw itzerland No No No Yes, reduction in physicians' fees Turkey Yes Preventive care Yes Preventive care Yes Process No

United Kingdom Yes

Preventive care, Chronic disease, Patient satisfaction

Yes Preventive care, _{Chronic disease} Yes

Clinical outcome, Process, Patient satisfaction, Patient experience Yes, reduction in physicians' fees

Note: (1) In some jurisdictions (e.g. Victoria) Note: n.a. means Not Available.

Source: OECD Survey on health system characteristics 2008-2009.

114. In France, a pay-for-performance scheme was introduced in 2009: generalist can sign, on a voluntary basis, individual contracts with the health insurance fund (Contrats d’amélioration des pratiques – CAPI). These contracts provide additional payments for the achievement of targets related to the quality of care (preventive activities, compliance with evidence-based guidelines) and to the efficiency of drug prescription (share of generics in some therapeutic classes). At the end of 2009, about one-third of all generalists had signed such agreements.

115. Eight countries reported the existence of bonuses for specialists. For instance, the United Kingdom mentioned that NHS consultants (68% of specialists) receive bonuses for targets in preventive care and the management of chronic diseases. In Poland, 5% of the specialists receive bonuses amounting to 5% of their revenues.

116. Six countries reported the existence of bonuses for hospitals. In Luxembourg, 9% of hospitals earn bonuses, which represent 1.4% of their revenues. In Belgium, the share of bonuses in revenues of hospitals is 0.5%. Only the Slovak Republic and the United Kingdom reported bonuses linked to all types of quality targets, i.e. clinical outcomes, appropriate processes, patient satisfaction and patient experience. 117. Ten countries indicated that physicians can incur penalties when volume targets are exceeded. In seven countries, penalties would take the form of reduction in physicians’ fees. In three countries, the Czech Republic, Finland and Italy, penalties would consist of partial refunds to health insurance funds.