In our market economy, we can buy
what we want, as long as it’s available, and we have the money. And we normally
expect the more expensive the product, the better the quality.
However, this is not the case in
healthcare, simply because we just don’t know if a better-skilled doctor or
surgeon, or hospital amenities, always means better care.
As a recent Grattan Institute report on private health
insurance states, in this context it would be fair for
“specialists with demonstrably better skills than their colleagues in the same
specialty” to charge more.
But the Grattan report goes on to
spell out the quandary over financing healthcare, saying: “Since the public has
no access to information about relative skill, such as complication rates after
taking account of the complexity of the patient, it is hard to justify the
higher fees that are charged. Higher fees are ... about what these doctors
think the market can bear.”
The underlying problem is that the
Australian healthcare system doesn’t have the systems and processes in place to
collect and analyse data to determine the true price of
quality healthcare.
We’re operating in the dark.
Technology can help to fix the
problem. But defining the desired result — beyond avoiding death or major
complications — varies according to age, general health, patient preference,
the severity of the particular problem, and what’s possible.
However, some moves are afoot to
rectify the lack of data on quality care and what it costs to deliver. One
initiative GPs will be well aware of is the new
Quality Improvement Practice Incentive Program (QI PIP) that aims to measure
the quality of care in general practice.
The scheme, rolled out earlier this
year, sees Primary Health Networks gathering data from participating practices,
which they analyse and feed back as advice on how they can improve by
identifying priority areas and quality improvement activities. Practices
receive a lump sum for taking part in the program.
A similar scheme in the UK that has
been running since 2004 goes a whole step further and pays GPs to meet specific
quality activities or outcomes that have been benchmarked using practice data
in what’s known as a ‘pay for performance’ scheme.
Writing in the BMJ last
month, advocate Dr Joanna Bircher, clinical director of Greater Manchester GP
Excellence Program, explains why GPs need to be at the forefront of determining
what amounts to quality care.
“Primary care
doctors have an important role in quality improvement. They need to be aware of
practice performance data and find ways to present it to the practice team and
patients in a meaningful way — for example, by considering variations in
practice demographics and list turnover.
“Feedback from participants of the
program indicates that it has improved job satisfaction and teamwork and
embedded basic quality improvement methods that practices can apply to other
aspects of care such as patient outcomes and access.”
There’s no hint at present of QI PIP
evolving into this kind of pay-for-performance scheme. But the UK program highlights
how far some jurisdictions have gone — especially when taxpayers’ money is
at stake — to link the delivery of quality care to healthcare financing.
As one can imagine, the UK scheme is
far from perfect, with mixed reports about its success.
One of the latest studies highlights
the complexity. The research, published in the New England Journal of
Medicine last year, looked at the impact of removing incentive
payments from a range of services in around 3000 general practices. It
examined changes in documentation of service provision after withdrawal of
incentive financing.
The results were mixed.
It found that documentation fell with
regard to lifestyle counselling in hypertension, cholesterol testing stroke and
TIA patients, and testing of glycated haemoglobin in those with serious mental
illness when the incentives were withdrawn.
However, the
simultaneous removal of pop-up reminders in the e-health record systems to
document care may have contributed to the decline, the authors say.\
They also point out that for any
quality improvement scheme based on pay-for-performance to be sustainable in
the long-term, incentives must, from time to time, be removed from ineffective
areas of care, so they can be targeted at effective services.
It’s clear that the relationship
between financial incentives and the delivery of quality care isn’t simple, and
those wishing to use payments to encourage all doctors to improve outcomes
should test their ideas first.
It is too early to say how the QI PIP
will unfold. But hats off to those GPs who have stepped up to the plate for
this experiment.
Published in the Medical Observer 12
December 2019 https://bit.ly/2T4uXp
