CAPÍTULO 5 RESULTADOS DEL ESTUDIO DE EVALUACIÓN
5.5. RESULTADOS POR ÍTEM
5.5.7. RESULTADOS EN EL ÍTEM 7
In this section not all of the findings as presented before in section 5.1 (page 71) will be repeated. Here only a summarized overview of the most important do’s and don’ts is discussed. The same notation of levels of evidence is used (‘S’ = strong evidence, ‘W’ = weak evidence, ‘C’ = conflicting evidence, ‘N’ = no evidence). In the case of conflicting evidence or an absence of evidence, the recommendations are based on theoretical grounds.
5.2.4.1 Quality goals and targets
1. Take all SMART aspects into consideration when selecting targets (including relevance and timeliness). (S)
2. Measure potential unintended consequences (especially in care equity, patient experience and provider experience). (S)
3. Consider both appropriate and inappropriate care, as both cannot be separated. (C)
4. In short term, make use of structure, process, and intermediate outcome indicators. Each of these indicator types has their own value (e.g. IT adoption enhancement as a structural goal). (S)
5. Keep the number of targets feasible and transparent, but also sizeable within the full scope of delivering healthcare. (S)
6. Make use of a cyclical and dynamical quality improvement approach. (S)
5.2.4.2 Quality measurement
1. Make use of validated data already available as much as possible. (N) 2. Provide an audit system to prevent and detect gaming. (N)
3. Apply case mix adjustment on intermediate outcome measures. (S) 4. Apply exception reporting to guard individualized care. (W)
5.2.4.3 P4Q incentives
1. Make use of a non competitive approach (C). Budget equilibrium can be guarded alternatively by applying a corrective factor on all P4Q incentive payments, equal in size for all participants (N).
2. Make use of rewards. Punishments can be reserved for gross negligence (N).
3. Reward both best performers and best improvers (N).
4. Follow theoretical indications about a sufficient incentive size (about 10% of total payment), since evidence is still inconsistent (C).
5. Provide free choice to providers to use the incentive to invest in quality or to increase income (see QOF example) (S).
6. Align the complexity of the system with the complexity of healthcare delivery. Use more transparent and clear means to communicate the incentive drivers to providers. (S)
7. Weight targets in short term in function of related workload and according to target type (structure, process, and outcome). Add in long term the related cost savings to this equation. (S)
5.2.4.4 Implementing and communicating the programme
1. Base the first P4Q programme on new money. To keep budget equilibrium couple already planned budget increases to the P4Q condition. (N)
2. Implement P4Q using a phased approach. Make initial use of demonstration projects to avoid unpleasant surprises. Include both baseline and comparison group measurements. (S)
3. Make initial use of a voluntary programme. Ensure by sufficient involvement (democratic decision making) and a sufficient incentive size that the majority of providers participates. (C)
4. Do everything possible to support communication and awareness of the programme, especially in a direct and intensive way towards the participating providers. (S)
5. Provide P4Q as a package together with other quality supporting tools. (S)
5.2.4.5 Evaluation of the programme
1. Incentivize a specific target for a sufficiently long time period (based on a learning curve and clinical criteria concerning the effect interval). (S)
2. When a target performance plateau has been reached, focus on maintenance of the level of quality of care. Include other priority targets to redirect quality improvement resources. (N)
3. Sample regularly the performance on targets removed from the incentivized set. (N)
4. Evaluate the P4Q programme as a whole on a regular basis, using scientifically valid methods. (N)
5.2.4.6 Health care system and payer characteristics
1. Include only targets congruent with the health system and provider values.
Ensure consensus. Make sure that the system fits with internal motivation and the non financial drive to provide healthcare. (N)
2. Provide one uniform P4Q system (in which local priorities may vary as targets) from all payers to all participating providers to support transparency, awareness and a sufficient incentive size. (S)
3. Integrate P4Q as one part of the healthcare payment system, with other incentive types. directed at complimentary goals (income security, patient and intervention volumes). (C)
5.2.4.7 Provider characteristics
1. Take into account the level of congruence with professional culture, but realize that P4Q may also support a cultural shift. (N)
2. Both when implementing and evaluating P4Q include the level of leadership support. The same is true for the history of engagement with quality improvement activities. (N)
3. Target incentives at least at the individual provider level, when he or she works in a larger organization. Combine individual incentives with team based incentives when appropriate (hospital setting). (S)
4. Be aware and take into account that provider age, gender, ethnicity, and training background will influence P4Q acceptance and performance. The same is true for the organization’s purpose and structure (see medical groups versus IPAs in the USA), the age of the organization, the ownership (degree of resources available), the (non)teaching status, its geographical location and the number of providers within a practice or organization. (W)
5.2.4.8 Patient characteristics
1. Monitor the effects of patient age, gender, socio-economical status, ethnicity and number of co morbidities on P4Q results. (W)
2. Take into account the experience of the patient as part of the targets, and during programme development, implementation and evaluation. (N)
3. Take into account patient influence when selecting targets and defining exception reporting criteria. (S)
5.2.4.9 Revision of the MIMIQ model
Figure 10 resumes the conceptual model that was presented in chapter 3. However in this version the results from the literature study are incorporated. For each item from the model, the strength of the evidence and the direction of the evidence are indicated.
However, it must be noted that for those items, where no evidence can be found yet, there might be still good theoretical reasons to take them into account when implementing a P4Q programme: no evidence does not necessarily mean no desirable effect. In Figure 10, this is formulated as ”best use of theoretical guidance”.
Figure 10: Revision of the MIMIQ model
Patient characteristics Demographics, Co-morbidities:
Closing performance gap with regard to patient age and unclear result with regard
to gender, and ethnicity (W) Socio-economics, Insurance status:
Unclear results with regard to socio economical deprivation level (W), Lack or
reporting on the influence of insurance status (N)
Information about price and/or quality:Conflicting evidence on the interaction of P4Q with public reporting (C) Patient behavioural patterns (cultural and consumer patterns, compliance):
Lack of reporting (N) Provider characteristics
Awareness, perception, familiarity, agreement, self-efficacy Other motivational drivers:Lack of reporting (N)
Medical leadership, role of peers, role of industry:Lack of reporting (N) Existence/implementation of guidelines, room for improvement:Lack of reporting (N)
Level of own control on changes:Lack of reporting (N), but in almost all studies (except smoking cessation studies) controllable measures were targeted. In addition most studies use intermediate instead of long term outcome targets.
Target unit (individual, group/organisation, …) and size:Evidence of positive effects on the individual and/or team level (S), Conflicting evidence on the level of an organization (medical group, hospital) and on the level of leadership (C).
In case of not-individual, size of unit (# providers):Conflicting evidence on solo vs. group practice performance (C), Positive relationship with the number of providers within a practice (W), No relationship with hospital size (W)
Role of the meso level (principal or agent):Lack of reporting (N)
Demographics (age, gender, specialty,…):Significant effect of provider age, gender, training background, geographical location, and having a second specialty (W), No significant effect of provider experience and rural vs. urban
location (W)
Organisational resources available and information systems:Weak evidence on the influence on P4Q effects, as measured through hospital/medical group/IPA status, age of the group or organization, organization vs. individual
ownership, and teaching status of an organization (W)
Organisational system change and extra cost/time required:Lack of reporting (N) Number of patients and services per patient:Conflicting evidence (C) Room for improvement:Strong evidence on the influence on P4Q effects (S)
Health care system characteristics Values of the system Type of system (e.g. insurance or NHS)
Level of Competition
Decentralisation of decision making and therapeutic freedom Dominant payment system (FFS, salary, capitation, ...)
Incentives
Incentive structure:Lack of evidence on diverse options, best use of theoretical guidance (N) Threshold value and/or improvement:In both a larger effect size for initially low performers (S) Weight of different quality targets: Weighting according to target specific workload and according to
sets of target types (S), Conflicting evidence on composite or all or none measures (C) Size (net additional income achievable):Conflicting evidence, best use of theoretical guidance (C)
Frequency:Conflicting evidence, best use of theoretical guidance (C)
Relative or absolute (competitive or not):Conflicting evidence, best use of theoretical guidance (C) Stable and long enough:Lack of evidence due to current P4Q initiation phase (N) Simplicity and directness:No apparent negative effect of back office complexity, when combined with
front office simplicity (S)
&
Communicating the program Communication to whom (providers, patients, ...):
High importance of provider communication and awareness (S)
Detail and terminology of the communication Quality of the communication Targeted or widespread communication:High
importance of direct and intensive provider communication (S)
Evaluation of the program
Sustainability of change:Target performance does not regress while being incentivized (S), There is an upper limit on target specific quality improvement (S),Lack of evidence on post
P4Q target performance (N)
Validation of the program:Evaluation is confirmed in peer reviewed literature (S),Lack of evidence on the use of evaluation
in programs with absent or elsewhere reporting (N) Review and revising the process:Too early stage and/or
insufficient use of continuous iterative quality improvement cycles
Financial impact and return on investment:see cost effectiveness results
Implementing the program
Involvement of providers in setting goals:Lacking and conflicting evidence, best use of theoretical guidance (C, N)
Mandatory or voluntary participation:Conflicting evidence, best use of theoretical guidance (C), No evidence of selection bias in terms of performance history due to
voluntary participation (W)
Staged approach of implementation:Modelling and piloting can prevent unexpected budgetary effects (S)
Stand alone P4Q program or embedded in a broader quality project:A bundled approach reinforces the P4Q effects (S) and serves as a recognition of the full
spectrum of non financial quality improvement initiatives Quality
Different (7) possible Quality dimensions: Effectiveness (S),Equity and access (W),Integration and coordination (W),Provider experience (W),Generic applications (W),Other domains (N)
Structure, process, and/or outcome indicators: Structure (S),Process (S),Intermediate outcome (S),Long term outcome (W)
Number of targets and indicators:Not too few (S)
SMART targets: A lack of attention for relevant and timely, based on room for improvement within a dynamical aproach
Quality measurement
Data source and validity: No difference in clinical results (S), Other domains (N) Case-mix: A lack of distinction between study and program risk adjustment utilization
Exception reporting (W)
Unintended consequences:At present not identified (W)
Payer characteristics
Mission/Vision of the payer:Lack of reporting (N)
Typology (Private/public/mixed):Scarce reporting of an absence of effect of these
differences (W)
Current use of clinical guidelines:lack of reporting (N)
Variable patient contribution:Lack of reporting in USA (N). In other countries no variable patient
contribution
Other incentive programs running:Important influence of a dilution effect by other incentive
programs when not aligned (W) Availability of information systems:The
different approaches do not translate into differences in clinical effect (S). Lack of reporting in
the included studies of payer and provider work experience effects (N).
Number of payers: see imp o rtance o f d ilution effects (W)
Accuracy of information system:Use of sufficient validity safeguards in most studies.
Evidence of gaming by providers to a very limited degree (W).
6 INTERNATIONAL COMPARISON
6.1 INTRODUCTION
This chapter aims at answering the following research questions:
How is P4Q applied and how is it influenced by market, payer, provider and other healthcare system characteristics.
Four countries are taken into account, the USA, the UK, the Netherlands and Australia.
For each country, semi structured interviews were conducted with key experts. (See chapter 2 for further details on the methodological approach)
From chapter 4 it appears that the majority of P4Q schemes are conducted in the USA and the UK. The Netherlands and Australia are two countries which are still in a starting phase of implementing P4Q, with only a few P4Q schemes operational. For the UK and the USA, two key experts per country have been interviewed. For the Netherlands and Australia, one key expert per country was interviewed. The results of these interviews will be reported in accordance with the topics of the conceptual framework as mentioned in chapter 3.