Tuesday, January 7, 2020

The difficulty of putting a price on quality care

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

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