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Linking Quality To Resource Allocation and Reward systems

George Boulton. Linking Quality To Resource Allocation and Reward systems. Topics Covered. What is quality? Quality myths Financing to achieve policy aims Linking quality to a capitation system Joined-up implementation issues. Quality in Health Care.

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Linking Quality To Resource Allocation and Reward systems

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  1. George Boulton Linking Quality To Resource Allocation and Reward systems

  2. Topics Covered • What is quality? • Quality myths • Financing to achieve policy aims • Linking quality to a capitation system • Joined-up implementation issues Quality Conference 2008

  3. Quality in Health Care • “It may seem a strange principle to enunciate as the very first requirement in a hospital that it should do the sick no harm” – Florence Nightingale (1859) • “Conformance to requirements” - TQM definition – Philip Crosby ‘Quality Without Tears (1984) • “Doing the right things, right” - J. A. Muir Gray ‘Evidence-based Healthcare’ (1997) • Donabedian (1966) advocated the assessment of quality through 3 approaches: Structure, process and outcome Quality Conference 2008

  4. Defining Quality in Health Care • Robert Maxwell Kings Fund, London (1984) identified 6 dimensions of quality: ACCESS: Geographical convenience, waiting time for appointment, hours of business, transport etc? EQUITY: Opportunity of access for equal need regardless racial, cultural and social factors RELEVANCE TO NEED: Over provision, gaps in services etc. SOCIAL ACCEPTABILITY: Is the way in which the service is provided acceptable to the population served? EFFICIENCY: Are the services delivered as efficiently as possible within the resources available? EFFECTIVENESS: Do the services provided attain the intended benefits in for the heath of the population served? Quality Conference 2008

  5. Quality Myths • Quality is separate from efficiency. Not so, quality is inextricably linked to efficiency e.g. TQM and DIRFT • Patients don’t understand quality. Not so, access to knowledge changing the doctor/patient relationship – the ‘intelligent’ patient • Quality is a `soft`, subjective issue. Not so, quality is as measurable as finance or activity • Quality is a system. Not so, it is a corporate culture, a mind set, a sub-routine as driving a car • Quality in health care is `accreditation`, `TQM`, `EBM`, `ISO 9001`, medical audit etc. Not so, these systems and approaches help develop and sustain a ‘quality’ culture. Quality Conference 2008

  6. Quality Sustaining Systems • Law and regulation • Accreditation • Visiting and inspection • Licensing & re-licensing of professionals • Professional codes and standards • TQM (based on prevention and DIRFT) • CQI/Quality Assurance • Evidence-based health care • Medical Practice variation (MPV) • Contracting • Care pathways, clinical guidelines, clinical protocols, clinical algorithms • Patient surveys • Complaints systems Quality Conference 2008

  7. Quality Sustaining Systems • Research and development • Health Technology Assessment (HTA) • Clinical governance • Clinical /medical/organizational audit • Patient-centered planning • Performance indicator systems • Risk management systems • ISO 9000, 9001,9002 etc. • Benchmarking • League tables • Star ratings – linked to accreditation • Continuous professional education and development • Contracting • Resource allocation and reward systems Quality Conference 2008

  8. Policy Outcomes for Primary Health Care? • Improved community/population health status • Reduced avoidable (amenable) mortality • Improved quality of life for the chronically ill and disabled • Morbidity compression related to the elderly • Higher volume and levels of cases resolved in primary health care • High levels of uptake (population-based) of PHC and preventive services • Increased patient satisfaction Quality Conference 2008

  9. Quality and its Link to Resource Allocation & Reward Systems • Capitation – a fixed sum per person paid in advance (usually 1 year) to a health care entity (e.g. DZ) for the provision of contracted health care services to an eligible person. • Capitation should be ‘risk adjusted’ for: • Population age structure • Gender structure • Health need differences (crude or standardised mortality rates • Poverty/social deprivation Quality Conference 2008

  10. Capitation Reimbursement Systems • Capitation can operate at two levels: • As a resource allocation formula to communities, hospitals or to PHC facilities • As part of the reward system to individual physicians and teams Quality Conference 2008

  11. Capitation Weaknesses • Capitation alone can produce low efficiency and effectiveness • It is often used in conjunction with complimentary and inter related financing streams: • Incentives for high quality or good practice • Rewards for high levels of performance • A typical resource allocation/reimbursement mechanism using capitation will often involve : Capitation + Incentive + Performance (85:15, 75:25, 60:40) Quality Conference 2008

  12. Joined-up Quality Strategy • How to link quality initiatives, approaches and systems to the resource allocation system? • A major quality initiative in Serbia is the Book of Rules on Health Care Quality Indictors • Linkage can be achieved through: • Developments in the contracting process to include quality systems, processes and targets • Use of the incentive and performance components of the resource allocation system • Use of the reward system Quality Conference 2008

  13. What Should the Financing System Support? • The development of the ‘Gatekeeper’ role • The integration of care (referral systems, care pathways, clinical networks, clinical protocols, care algorithms etc.) • Increased focus on health promotion and primary and secondary prevention systems • Emphasis on early identification, management and control of chronic disease and illness • Continuous quality improvement and innovation Quality Conference 2008

  14. What Should the Financing System Support? • Increased focus on health maintenance and quality of life issues for the long term chronically sick • Evidence-based practice (appropriate antibiotic use, call and recall screening etc.) Compliance with best practice guidelines/protocols • Increased levels of community/patient satisfaction with PHC • Efficiency and effectiveness in service delivery Quality Conference 2008

  15. Finance-linked Performance Examples • New Zealand is currently in the process of implementing capitation payment system and divides the incentive and performance components into: • Clinical performance issues • Process/capacity performance issues • Financial performance issues Quality Conference 2008

  16. Examples : Clinical • Proportion of children fully vaccinated by x age from target population • Proportion of cervical smears in accordance with protocol from target population • Breast screening undertaken in accordance with protocol from target population • Inhaled corticosteroids – average inhaled doses • Ratio of metformin to sulphonylurea prescriptions • Investigation of thyroid function (TSH v T4) • Ratio ESR to CRP test ordering • Flu vaccinations for +65 from target population Quality Conference 2008

  17. Examples : Process/capacity • Number/proportion of patients registered from catchment • Number/proportion of cases resolved in PHC • Emergency admissions to hospital for chronic conditions • Number of new patients attending for a new episode of treatment • Waiting times for treatment and in facilities against targets • Rate of blood pressure checking for over 40s compared to target population • Patient satisfaction (as measured by survey) • Introduction of audit systems Quality Conference 2008

  18. Examples : Financial Performance • Compliance of activities, outputs to planned • Compliance of expenditure to budget • Pharmaceutical expenditure in comparison with benchmarks • Laboratory expenditure in comparison with benchmarks • Antibiotic prescribing patterns (1st gen/3rd gen) • Proportion of prescriptions expressed on a generic basis Quality Conference 2008

  19. OECD Quality Indicators for Health Promotion, Prevention, PHC (HTP No. 16) Quality Conference 2008

  20. Practical Implementation Issues • The urgent need for a population data base (registration) at DZ level to help shift from a curative to a preventive service • How to link existing quality assurance system (book of rules of Health Care Quality Indicators) to the financing system to avoid duplication of effort? • Convert averages to targets (top 25 percentile performance), rates of screening to target populations etc. • Beware over complicated, non-transparent formulae and incentive arrangements that can be self-defeating • Need for financial flexibility and incentives at DZ level to promote and stimulate innovation and continuous quality improvement? Quality Conference 2008

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