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International Research on Quality in Healthcare

Final Report Summary - INTERQUALITY (International Research on Quality in Healthcare)

Executive Summary:
1. Executive Summary
Most important question facing nowadays all EU Member States is how to meet public demands and needs in terms of healthcare while facing economic and financial pressures. Contemporary healthcare financing systems tend to make cost, quality, and coverage problems worse by rewarding volume, regardless of quality or patient outcomes and paying for procedures and services, regardless of whether they are appropriate or needed. Usually, these systems value expensive technology over patient-centred care and pay richly for acute care but not for the primary and preventive care that keeps people healthier in the first place. Increasing healthcare spending often does not improve quality, efficiency or availability of healthcare services. Therefore, there is an urgent need for innovative models of payment and care delivery, anchored in primary care and focused on ensuring that every patient gets the right care, at the right time, for the right reason. Almost all EU Member States are in favour of supporting innovation but there is little understanding for innovations in healthcare organisation and management and even less in healthcare financing.
Nevertheless, more and more people recognize that 21st century medical technology may not be efficiently delivered by 19th century institutions and financing models .Innovations in healthcare organisation and management may reduce costs and improve quality. Hybrid US healthcare system facilitates implementation of innovative institutions and financing models. InterQuality mandate was to investigate the feasibility of implementing innovations proven in US, in EU MS.
The first two Work Packages of the InterQuality Project provided detailed theoretical background for empirical research, using the concepts and methods of New Institutional Economics (Olivier Williamson, Nobel prize 2009), based on the Agency (Principal-Agent) Theory and transaction costs analysis .The main findings of the first two Work Packages were that there is no clear correlation between financial incentives and outcomes/ costs. Provider behaviour depends significantly on the number of factors beyond payment method itself. The research confirmed the key importance of systemic and institutional context .
Market regulators inability to observe agents private information was perhaps most evident in the case of physicians or pharmacists, expected to act as patient’s agents in some health care systems, like Germany or UK, analysed by Work Package 3 - Pharmaceutical Care. This may explain why US Government prefers to use as agents, managing Medicare Drug Benefit, “Prescription Drug Plans”, whose business model is far more transparent and easier to observe.
The main conclusion of research on Hospital and Outpatient Care financing models is that the impact of financial incentive schemes on quality is strongly affected by the institutional set-up of the health system of the country in which they are operating.
According to Work Package 6 – Integrated Care - the greatest challenge in the design of healthcare systems is the optimization of the communication between and the coordination of activities of different healthcare providers. The complexity in this regard is not the optimization of the individual unit services, but the interaction of different providers in coordinated healthcare delivery processes (for instance in the form of disease management programs). Integrated healthcare represents an ideal type of selective contracting that requires the search and engagement of appropriate partners as well as the implementation of proper incentive structures.

Project Context and Objectives:
2. Project context and objectives
Spending more on healthcare often doesn’t result in improving quality, effectiveness and access to service. In several countries higher rates of physician consultations, hospital beds, or medical prescriptions per citizen result in wasting resources as compared to other countries, which have introduced modern co-payment systems, provided with safeguards, like “annual caps” or “doughnut holes”. In the latter case the overuse of resources caused by moral hazard is reduced by empowering patients. Resources that are wasted because of poor management are no longer available to reimburse innovative pharmaceuticals, buy new equipment, shorten waiting lists and improve other essential quality indicators.
To improve and modernize health care financing systems different reforms are being implemented in United States and in Europe. But even experienced executives of US health insurance companies admit that: “Our current payment system is making cost, quality, and coverage problems worse by rewarding volume regardless of quality or outcomes and paying for procedures and services regardless of whether they are appropriate or needed. These systems value expensive technology over patient-centred care and pays richly for acute care but not for the primary and preventive care that keeps people healthier. The good news is that we can realign payment incentives to drive quality improvement and foster better use of our health care resources. To get to better quality, we don’t need to pay more: we need to pay smarter.
Health care financing reforms implemented in Central and Eastern Europe have proven various technical and political difficulties. Scientifically validated tools to help decision-makers choosing the right financing mechanisms in the different areas of healthcare systems are vastly needed.
A key marker of the successful healthcare system is the extent to which it facilitates the delivery of efficient, effective and equitable care. While healthcare systems differ in such core elements as the characteristics of the population base or funding, reimbursement and pricing systems, the design and implementation of reform measures is mainly geared towards optimizing the relationship between input and output (quality, outcome) factors.
Project objectives:
o To investigate the effect of different financing methods and incentives on the quality, effectiveness and equity of access to health care in four patient groups affected by:
• pharmaceutical care
• hospital care
• outpatient care
• integrated care
o To develop collaborative practice models of healthcare, in the context of financing treatment of chronic diseases
o To establish the feasibility and effectiveness of developed models in the settings of each partner healthcare system
Research areas:
• Incentives
• Clinical issues: quality outcomes, clinical efficacy and safety
• Economic issues: cost control, cost-effectiveness, utilization of resources
• Equity

Project Results:
3. Main results
3.1. Impact of financial incentives on the quality of healthcare- state of the art
In order to provide methodological basis for further research, a typology of payment systems for physicians, hospitals and integrated care systems was developed. At the beginning, the financial incentives were placed in the context of overall incentives and brief review of important non-financial incentives that act to influence provider behavior as well as key financial incentives that influence patient care-seeking behavior was taken. Next, a number of examples of how actual payment methods reflect specific design elements that can fundamentally alter the nature and power of the incentives provided were provided. Afterwards, a number of proposed frameworks with which to organize payment methods, emphasizing the dimensions that define different payment systems, were presented. However, a payment systems typology was only considered a starting point for discussion.
Subsequently, the systematic review in medical databases (Medline and Embase) was conducted with aim to review the existing knowledge of provider payments systems impact on quality, costs, utilization, efficiency and access. The review was focused on payment systems relating to four categories of health, subsequently analyzed in empirical WPs - namely physician care, hospital care, non-hospital care as well as integrated care. After the deduplication process, a total of 10,950 abstracts was retrieved from medical databases and searched against the pre-defined inclusion criteria. Then, 1 031 publications was included into full-text review. Finally, 129 studies were included - therein 73 studies concerning physician payment systems, 34 studies evaluating hospital payment systems, 24 studies regarding non-hospital care and also 6 studies evaluating integrated care. The systematic literature review strongly suggests that the impact of a payment method on provider behaviour depends crucially on a number of factors independent of the payment method itself. In the description of review results, the factors that help explain the findings, such as the relative generosity of the payment level and the institutional context in which the payment model is being implemented, were pointed out. For physicians and hospitals, the two provider categories for which large numbers of qualified studies have been identified, no statistically significant effects on quality, cost and utilization, or access were found, or the effects were significant and, in the anticipated direction, based on the objectives of the payment method in use. Studies for physicians payment did not generally demonstrate FFS to be more expensive than capitation or salary, contrary to expectations; studies of the effect of including more services within capitation did show savings, as expected; P4P programs focused on quality improvement were generally cost-increasing. For hospital payment, no substantial effect of P4P has been found on selected quality measures nor on patient experience; case rate payments were shown to lead to shorter lengths of stay than the other payment approaches. One more observation deserves mention. Using conservative inclusion criteria to ensure only studies with rigorous methods have been included into the literature review, the very extensive review was made, in which the evidence tables for 129 included papers were developed. Yet, many of the qualified studies were relatively recent pay-for-performance studies, as if the effects of basic payment approaches on quality, cost and access had been already settled. The remaining question is whether the current body of rigorous studies combined with other studies and, more likely, practical experience provides enough information on which to set payment policies. This may be ameliorated to the extent that governments, public and private insurers, provider organizations, and other interested parties have available proprietary analyses to help affect policy decisions, although the extent of these parties’ research activities (and their findings) are generally not publicly available.
Additionally, review and summary of currently used payment methods for physicians and hospitals in European countries was performed. In-depth review of the European Observatory on Health Care Systems and Policies (EOHCS) as well as the Organization for Economic Cooperation and Development (OECD) sources was taken in order to recognize the payments methods used in practical settings. Finally, information on 23 European, member countries of OECD were presented. Results of the review were summarized separately for physician payment methods and hospital payment methods. Furthermore, information on physician payment methods was divided into three categories: primary care specialists, outpatient specialists and inpatient specialists, in order to make it more transparent. In addition to payment methods, information on institutional characteristics, recent health system reforms and national programs (for instance, P4P programs) were shortly outlined.
In parallel, a literature review aimed at identifying indicators and measures for quality, efficiency, outcomes, risk adjustment, costs and equity was conducted. However, in this case the systematic literature review was considered not to be the only proper method. Therefore, the review was based on previous experience of project partners and complemented by hand searching of books, monographs and websites as well as references of publications found. As there is no general consensus on the ‘quality of healthcare’ definition, nor on the aspects of care that should be measured to assess quality, the definition of the Institute of Medicine (IOM) was adopted by the InterQuality project: “Quality of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge”. Quality of health service depends on structural aspects (the potential to ensure quality), process (performance) and outcomes. Organisational and clinical quality assessment are two dimensions of measuring quality; the former include accreditations and ISO, EFQM (European Foundation for Quality Management), EPA-PM (European Practice Assessment Practice Management) certificates, and the later - clinical practice guidelines, peer review procedures, consumer surveys, rankings, as well as monitoring patients adherence, compliance and persistence.
The main aspect of quality seems to be efficiency, which stands for economic concept coupling effects and costs in one measure. However, one should be aware of a certain dualities and difficulties while tackling this problem. The first and probably most puzzling difficulty is the perceived lack of interrelation between output and outcome in health production. The second one is the apparent conflict between standardized, average outcome advocated by NICE or IQWIG, and individual patient’s outcome which may or may not be optimal from the standpoint of a nationwide or regional healthcare provider. Accordingly, a distinction between the optimal usage of production resources in order to perform the procedure and the end result of such an action – i.e. distinction between output and outcome, should be kept in mind. Moreover, the construction of an efficiency measure should take into account both the cost-effectiveness of a procedure per se and its effectiveness as measured in health gain both per patient and per society
Outcomes are in the central interest of patients and payers. Validity and stability of such indicators is irrefutable; their concreteness allows precise measurement. Outcome measures, in contrast to structure and process indicators, are able to reflect aspects of care which are observable as well as unobservable to the payer, however, being indicative of beneficial or adverse events in healthcare, they usually do not identify its cause or nature. Still, there is a number of considerations limiting the use of outcome indicators: most of the commonly used quality indicators concern hospital care, which makes them irrelevant in relation to outpatient care and chronic diseases, which are not fatal or acute but lead to decrease in quality of life or disability.
Fundamental issue is the dependence of outcomes on many other factors apart from quality of care. Therefore the difference in case-mix of patients must be taken into account if outcomes based comparison between providers is to be considered valid. In order to compare outcome measures of alternative healthcare providers risk adjustment has to be applied. The definition of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO): “the use of severity-of-illness measures, such as age, to estimate the risk (measurable or predictable chance of loss, injury or death) to which a patient is subject before receiving some healthcare intervention” is recommended.
The costs of a procedure or a treatment – another measure influencing efficiency – are a crucial factor both in the decision of performing a service as well as in paying for it fully or partially. While the markets for medical services are far from economic freedom and many imperfections exists, one can measure only the costs of a single chosen procedure with a 100% certainty, and even that only ex post. Furthermore, the process for services is usually locked, either locally or at the nationwide level. This makes us doubly cautious when approaching the topic of costs and costing.
There are definitely a lot of costs’ taxonomies, but one of the most important fact is that when dealing with economic costs, not social ones, one usually deals with an artificial category called ‘the accounting cost’ – i.e. costs as they were registered in the books of the healthcare provider. These costs represent an approximation of financial value of outlays and resources that were expanded in the process of providing a service. When assessing the real life meaning of costs in healthcare system one should remember opportunity costs – which mean the cost of lost opportunity to finance a procedure or provider when reimbursing another one. Additionally, one should remember the costs which are harder to estimate – indirect or societal costs; these are costs of underperformance due to illness or adverse effects of treatment, and it goes not only for patients but for their families as well.
Another quality aspect, commonly overlooked or underestimated is equity. The InterQuality project understood ‘inequality’ as referring to the description of differences in health observed in populations and its distribution. However, the conclusion of WHO 2003 report is that “There is a growing consensus that an improvement in average levels of health is not a sufficient indicator of health systems performance”. The InterQuality project focused attention on the distribution of resources and other processes that drive a particular kind of health inequality – that is, a systematic inequality in health (or in its social determinants) between more and less advantaged social groups, in other words, a health inequality that is unjust or unfair.
• Robert A. Berenson, Jonathan H. Sunshine, Arkaprava Deb, Julia A. Doherty, Ellen T. Kurtzman, ElizabethS. Richardson, Noah S. Kalman, Juliana Macri, Christian Kronborg, Urszula Ceglowska, Tomasz Hermanowski, Anna Zawada. Deliverable 1.1. Project Methodology Guidelines, Part 1. The Effect of Provider Payment Systems on Quality, Cost, Efficiency, and Access. Version 0.1 06/2012. International Research on Financing Quality in Healthcare, InterQuality Project (Grant Agreement 261369) Interim Report.
• Tomasz Hermanowski, Joanna Lis, Anna Zawada, Giacomo Pignataro, Guccio Calogero, Victor Bystov,
• Anna Staszewska‐Bystrova, Krzysztof Rogalski, Aleksandra Drozdowska, Dominika Duleba, Urszula
• Ceglowska, Jakub Rutkowski, Szymon Zawodnik. Deliverable 2.1. Project Methodology Guidelines, Part 2&3. Guidelines for further project activities on comparative evaluation of quality, economic and equity issues in healthcare systems. Version 11.4 31/07/2012. International Research on Financing Quality in healthcare, InterQuality Project (Grant Agreement 261369) Interim Report
• Institute of Medicine, Crossing the Quality Chasm: a new health system for the 21st century. March 2001 March 5th, 2014
• Joint Commission on Accreditation of healthcare Organizations, Lexikon: dictionary of healthcare terms, organizations, and acronyms for the era of reform, 1994
• Murray CJL, Evans DB (eds). Health systems performance assessment. Debates, Methods and Empiricism. WHO, Geneva, 2003, p. 481
• Braveman P, Gruskin S. Defining equity in health. J Epidemiol Community Health 2003;57:254‐258

3.2. Hospital care
3.2.1. Scope of research
The core of the research activity in the field of hospital care has been to investigate the effects of different prospective payment systems (PPS) on the quality of hospital care, taking into account how they are affected by relevant features of the health care systems. In general, the main objectives were :
• to compare payment systems for hospital care in selected countries (i.e. Italy, Denmark and the UK);
• to theoretically analyse the effects of PPS as related to important characteristics of health care provision;
• to empirically analyse the effects of the use of PPS on hospital care provision in the Italian regions;
• to replicate the empirical analyses in other countries (i.e. in our case, Denmark and the UK).
Then, the results have been employed as a comparative basis for providing a robustly founded characterization of the effects produced by PPSs, in terms of relevant characteristics of the health care systems. Therefore, this characterization has been used to develop policy recommendations on the desirability of the adoption of PPS for financing hospital care and, in turn, to define a set of financial (and non-financial) tools, which could be used to design the financing system, once the peculiarities of health systems are considered.
3.2.2. Summary of research
The first part of the analysis have offered an overview of the organization and financing of hospital care provision in three European countries: Denmark, Italy and the UK. The characteristics of these payment systems have been framed within the general features of prospective payment mechanisms. The description of the health care arrangements in place in each of the three countries under consideration has highlighted some broad similarities but also many substantial differences among them. In terms of similarities, all the three countries rely on tax-funded, publicly administered national health care systems, provide universal coverage and health services free at the point of use and deliver services mainly through public providers. Moreover, they have all opened up their national health systems to internal competition to diversify supply as well as to increase purchasing power and have devolved health responsibilities to subnational governments, albeit with different emphasis and modalities. There are, however, substantial cross-country disparities in how activity-based funding has been actually implemented and developed over time, since each country has tried to tailor hospital payment mechanisms to its local context. In particular, the cross-country comparison of the hospital DRG-based payment schemes has found differences with regards to many DRG design features such as number of groups, type of costing, funding characteristics of particular hospital activities, specific adjustments, reimbursement of outliers and so on. Nonetheless, considering these dissimilarities alone does not allow to fully appreciate the effect of a country-specific DRG-based payment scheme on the achievement of the typical PPS incentives for cost efficiency, quality and equity of access.
Evidence on the impact of the hospital funding reforms implemented in the last decades, usually introducing some form of PPS and reducing the scope for retrospective global budgeting, does not seem to have established very clear-cut results. In particular, factors that might bear on the actual realization of the expected incentives provided by PPS are potentially quite numerous. To this extent, the second part of the analysis has been devoted to theoretically evaluate those features of the health system which are considered to be particularly crucial in affecting the result of PPS on hospital efficiency and quality. In particular, the discussion has been divided into “design features”, those concerning the specification of the payment system (e.g. prospective budget vs. prospective price, readmission policies, etc), and “institutional features”, those concerning the context in which the PPS is implemented (e.g. degree of competition, public-private mix, etc.). The general picture emerging from the analysis is that the main features of the context in which a given payment system is implemented are certainly relevant in driving hospitals’ behaviour and, in turn, in affecting the level of efficiency and quality induced by that payment system. Specifically, the public-private mix of hospitals, the degree of competition and the extent of non-financial motivations turn out to be crucial in establishing what payment system should induce the best performance in terms of both efficiency and quality. Similarly, relevant design features as the readmission policies and the degree of soft budget constraint also appear to be very important in affecting the results expected from PPS.
Finally empirical analyses of the effects of the PPS adoption on different efficiency and quality issues in Italy have been carried out, using various methodological (parametric and non-parametric) approaches. Firstly, the efficiency of Italian hospitals is considered. For this purpose, a two-stages efficiency analysis has been conducted, where in the first-stage the Data Envelopment Analysis (DEA) efficiency scores are estimated for all Italian hospitals and, then, in the second-stage, the above scores are regressed on different explanatory variables, aiming at capturing the role of regional financing systems. Indeed, evidence is found that hospitals financed through PPS tend, on average, to be more efficient than those financed through global budget. As a further step, an analysis of the impact of PPS on different dimensions of hospital quality, such as standard outcome-based indicators, diffusion of medical technology and inappropriateness, is carried out. As far as the investigation of outcome-based indicators is concerned, the analysis of the Italian hospital system relies on data from the National Program for Outcome Assessment on mortality and readmissions for Acute Myocardial Infarction (AMI), Congestive Heart Failure (CHF), stroke and Chronic Obstructive Pulmonary Diseases (COPD) in the years 2009–2010. Results show that hospitals operating in regions where PPS are used more extensively are generally associated with better quality of care. A similar empirical analysis has been then replicated for Denmark, where the impact of an activity-based hospital financing system on readmissions for chronic obstructive pulmonary disease (COPD) is considered.
All in all, empirical findings for Italy tend to confirm theoretical predictions and further strengthen the positive impact of PPS on hospital efficiency, quality (as measured by outcome-based indicators), medical technology diffusion and appropriateness of care (as measured by cesarean section rates). The analysis for Denmark also shows that key design elements of the prospective hospital reimbursement system (i.e. operating above baseline and having high reimbursement rates) do have an impact on quality of health care as measured by the risk of readmissions for COPD.
3.2.3. General conclusions
The general picture emerging is that DRG-based PPSs do not seem to induce a significant worsening of quality of care. Nonetheless, our results emphasize strongly that the main features of the context in which a payment system is implemented are certainly relevant in driving hospitals’ behaviour and, in turn, in affecting the performance induced by that payment system. The overall conclusion coming out from our research is that, despite the effects of PPS are not all desirable, is not the time yet to abandon PPSs for financing hospital care; rather, the right direction is to consider more carefully the role of the specific design features of the payment system, as well as the features of the context where the payment system is implemented. Indeed, the role of the specific design features should be viewed as a tool in the hand of the regulator and, more specifically, incentives should be designed exactly to counteract the undesirable, and to reinforce the desirable, effects of a typical PPS. To this extent, we believe that the results of our research and, in particular, the policy recommendations provided will be certainly useful for policy makers for moving a step forward toward an optimal design of DRG-based PPS.
• Giacomo Pignataro, Xenia Brun Bonde, Marina Cavalieri, Massimo Finocchiaro Castro, Lara Gitto, Calogero Guccio, John Hutton, Line Planck Kongstad, Christian Kronborg, Jørgen Trankjær Lauridsen, Domenico Lisi, Alfia Mangano, Ilde Rizzo. Deliverable 4.1. Report on Financing Hospital Care. V. D 4.1 09/2013. International Research on Financing Quality in Healthcare, InterQuality Project (Grant Agreement 261369) Final Report
• Giacomo Pignataro, Marina Cavalieri, Calogero Guccio, Domenico Lisi. Deliverable 4.2. Reports on Recommended Financing Models for Hospital Care. V D 4.2 0.5 12/2013. International Research on Financing Quality in Healthcare, InterQuality Project (Grant Agreement 261369) Final Report

3.3. Outpatient care
3.3.1. Scope of research
With respect to outpatient care, we aimed to review the evidence on the impact of financial incentives on the quality of care delivered outside the hospital setting, and to identify the most appropriate financial mechanisms to enhance quality in these services in European health care systems. We exploited the definitions of outpatient care to include traditional primary care provided by General Practitioners (GPs) as well as community support services provided to patients before and after hospital treatment. Community-based specialist services and the non-hospital elements of independently run services, such as mental health care, were also considered as outpatient care.
Our work was mainly review-based and involved international comparisons. It was decided to focus on those areas of outpatient care for which published information was likely to be available, for which a range of funding models might be observed in the countries of interest and which covered the bulk of expenditure on outpatient care in most countries. Traditional primary care is a major element of outpatient care, and much of the analysis addressed financial incentives and their impact on service quality in this sector.
3.3.2. Summary of research
The full range of financial mechanisms to reimburse health professionals can be seen in the outpatient care sector. These range from activity-based methods such as fee-for-service to fixed income methods such as salaries and capitation. Most systems use a combination of guaranteed income and fee-for-service. As the first point of contact for the patient e.g. in primary care provided by GPs, the health professional providing outpatient care has the option of referring the patient to a specialist, for a confirmatory diagnosis or more specialised care. GPs remunerated by salary or capitation have less of a disincentive to refer than those on fee-for-service, as their income is not affected and their workload may be reduced.
The conventional dimensions of quality of service – effectiveness, accessibility and patient experience – are all relevant. The patient will want effective treatment provided by the appropriate person as rapidly as possible, so effective outpatient care may be as much about a GP’s skill in deciding when to refer to specialists as in the direct provision of care. The speed of diagnosis and referral and the availability of post-operative community care can be the major determinants of the effectiveness and efficiency of the whole process. Accessibility of outpatient care is influenced by the number and geographical spread of practitioners. In the case of GPs the time to get an appointment is important, as well as the out-of-normal-hours service provided overnight and at weekends. Special payments can be made to encourage GPs to practise in rural areas where the population is insufficient to generate a reasonable income from the capitation reimbursement formula. Patient experience is central to the quality of outpatient care. It will determine their willingness to access services in a timely way and have an impact on the effectiveness of the care which is ultimately delivered. Time spent with each patient is often used as an indicator of the quality of GP consultations, and the various mechanisms of remuneration for GPs give different incentives to shorten or prolong consultations. For example, if there is a fee per consultation regardless of its length there is a financial incentive to deal with each patient as quickly as possible. If remuneration is based on capitation or salary there is less of an incentive to speed up the process. In the latter case, of course, there could be an impact on accessibility for all patients if a long time is spent on each consultation, and hence on the effectiveness of the service. It can be seen that financial incentives need to be coupled with other types of incentive, such as professional ethics, if outpatient care providers are to make the correct trade-offs between effectiveness, accessibility and a good patient experience.
The extensive literature reviews undertaken in theoretical phase of the Project did not find many good quality studies of the impact of financial incentives on the quality of outpatient care services. Those examples which were discovered focussed on specific services rather than the sector as a whole. It was decided to supplement the these findings with further surveys in individual countries related to some specific policy changes focussed on the improvement of the quality of outpatient care. The main example of this was the Quality and Outcomes Framework (QOF) in the primary care sector in the UK.
QOF was introduced in 2004 to raise the quality of service provision in the outpatient sector. This initiative links about 25% of the NHS payments to GP practices to the achievement of explicit quality standards. In WP5 empirical evidence was sought to answer the following key questions for any of the disease areas included in the QOF. Once a measurable indicator of performance against best practice standards has been identified, movement towards best practice can be observed. If such a move is observed, is it the result of the financial incentive? If it is accepted that the improvement is the result of the financial incentive, are the benefits proportionate to the payments? If the payments are judged proportionate (i.e. cost-effective) how long do they need to be maintained to sustain the enhanced level of performance?
A general literature review (Steel and Willems, 2010) found evidence that overall achievement of QOF targets increased in each of the first three year; specific disease areas, such as diabetes, CHD, TIA and blood pressure management, also showed noticeable improvement. The evidence of a causal link between QOF and improvement is not consistent across disease areas. A study of English GP practices used the improvement trend in asthma, CHD and diabetes care from 1998 to 2003 to predict care levels in 2005. The 2005 data were better than the predicted trend for asthma and diabetes care, but not for CHD (Campbell et al, 2009). Other studies gave mixed results for diabetes care, showing increased achievement up to 2005 but a reduction in the rate of improvement after that. However, there is some evidence that activities within QOF showed increased improvement compared with those not incentivised. For example, Doran et al (2011) compared the achievement rates for 42 GP activities before (2001-2003) and after (2005-2007) the introduction of QOF. For 22 of the 23 activities incentivised in the QOF a significantly increased rate of improvement was seen in 2004-5, the first year of the scheme. The improvement attenuated after that but the quality of care remained higher in 2006-7 than predicted by pre-QOF trends. For the 19 activities not incentivised in the QOF there was no effect on the rate of improvement in 2004-5, but by 2006-7 achievement rates were below those predicted by the pre-QOF trend.
Fleetcroft et al (2010) found evidence from controlled clinical trials that mortality reduced for 25 out of 80 indicators in the 2006 and 2006 QOF contracts. The potential impact on mortality from achievement of QOF target performance rates and 100% performance were estimated using prevalence and risk reduction data. For the 2004 contract it was estimated that an additional 11 lives per 100 000 would have been saved if all practices had achieved the target levels for the full incentive payment. For 2006 there was no additional mortality gain as the baseline performance already exceeded the target levels. If all eligible patients were to receive treatment beyond the target level for full payment a further 56 lives per 100 000 might have been saved in 2004. The equivalent figure for 2006 was 30. However, No link could be established between the marginal gains in quality-adjusted life-years (QALYs) expected from achieving target performance levels and incremental QOF payments. Evidence of potential QALY gains was found for only 9 indicators by Walker et al (2010). Using the NICE threshold level of cost per QALY (£20 000 - £30 000) they found that the proportional change in achievement needed to make the QOF payments cost-effective varied from 0.06% to 20% across these 9 indicators. From this they concluded that for most of the 9 indicators QOF incentive payments are likely to be a cost-effective use of NHS resources.
3.3.3. General conclusions
Background contextual knowledge should be used to help determine the generalizability of experience with the QOF to other countries and health systems. The impact of financial incentive schemes for quality is strongly affected by the organisation and financing of the health system of the country in which they are operating. There are two main models of health system in Europe: social insurance model financed by contributions from employers, employees and the state, and the centralised national health services financed from general taxation. In reality, most European health systems are a mixture of both types of organisation. In the social insurance systems, there is a degree of choice of provider for patients. The income of providers mainly comes from fee for service (FFS) reimbursement. In the national health services, patients normally have limited choice of providers and the income is based on salary for hospital doctors and capitation for GPs.
FFS reimbursement is closely linked to the volume of patients seen, and tends to encourage increased provision. It can make providers very responsive to patient demands and increase the availability of services, scoring strongly in the accessibility and patient experience dimensions of quality. However, from the providers’ perspective, FFS does not guarantee stability of income, and may lead to a geographically uneven distribution of provision. In the absence of other controls the FFS approach may lead to provision which goes beyond that which is effective or cost-effective as suppliers try to maintain income levels. Capitation funding gives providers an income which is independent of the level of service activity undertaken. Payments are based on expected average costs per patient, so providers are expected to provide services on demand. Thus they have reduced uncertainty over their income, but are at risk over costs which may vary from year to year. Capitation is likely to contain the cost of the primary care provision, but whether this produces the most effective service for patients (and the most cost-effective overall health care provision) depends on the quality of the providers and their response to non-financial incentives, such as professional standards. The main models of health care financing in Europe involve some element of direct out-of-pocket expenditure by patients. In outpatient care examples of this are to be found in dental and ophthalmic services, and in pharmaceutical prescriptions in the community. A significant impact on access to care can occur where there is a charge for access to services, such as GP consultations. Patients can often take out supplementary insurance to pay for services not covered by the main insurance programme. Where this is not readily available, the inability or unwillingness of patients to pay for care will destabilise the income of providers and exacerbate any perceived issues regarding the quality of the service.
Contemporary policy context is another important element in the background to the design of incentive systems, as the appropriate incentive mechanism will vary with the policy objective. If the aim is to expand certain types of service provision, then the use of FFS reimbursement may be more effective than capitation in inducing providers to increase service provision. If on the other hand the policy aim is to stabilise demand, and perhaps reduce less effective care, then fixed budgets and capitation funding may be more appropriate. In general, the policy context should consist of the following elements: macro-economic situation, demographic trends, public awareness and understanding of health care issues, providing care closer to patient’s home, focus on the outcome of health care, competition between providers and patient’s choice, and integration of services from different providers along patient pathway.
The UK QOF has been seen as a successful incentive scheme, in terms of its impact on GP behaviour. To understand its impact it needs to be seen in the context of the health system for which it was designed and the health policy context at its initiation. Specifically, The QOF was introduced at a time when a major increase in health service budgets was being implemented, and was part of a substantial increase in payments to GP practices. The indicators of performance used, and the distribution across the indicators of the financial rewards attached to their achievement, were chosen in negotiation with the GPs. The existence of well-established computerized information systems in many GP practices enabled the collection of reliable data and gave reassurance to the NHS and the DH that the scheme could be effectively monitored. In term of contemporary policy, QOF was introduced when there was a widespread belief in evidence-based decision-making and the QOF indicators could be linked to evidence-based practice. Moreover, delivering health care closer to patients’ homes was a key policy which increased the role of the GP. Last but not lease, there was a move to assess policies in terms of their impact on patient outcomes and QOF indicators were a way of doing this.
The QOF has demonstrated that it is possible to design and implement relatively sophisticated incentive systems which improve the quality and cost-effectiveness of care. Taking into consideration of local health system and health policy context, we recommend that:
• A mix of reimbursement mechanisms is likely to give the maximum flexibility to incentivise appropriate care;
• Incentives must be aligned between providing sectors and between providers and funders;
• Optimal service provision should be evidence-based and cost-effective;
• Tight monitoring is needed to prevent ‘gaming’.
One of the dominant policy themes in many European countries at present is the integration of care along the patient pathway in order to improve the effectiveness and cost-effectiveness of services. To achieve this it is necessary to identify the appropriate location of each stage of care and to design a financing system which provides incentives for care to be delivered at those locations. Solving the problems of financing integrated care cannot be done by simply funding all services out of one budget. From our analysis the following key recommendations emerge:
• For each type of service provision a mix of reimbursement mechanisms is likely to give the maximum flexibility to incentivise appropriate care;
• At the margins between providers where transfer of activity is desired, matching positive and negative incentives may be the best option. e.g. DRG-type payments for activity in primary care and fixed budgets for secondary care;
• The optimal location of care should be determined by evidence-based analysis of effectiveness and cost-effectiveness;
• Effective monitoring is essential to ensure that performance targets linked to payments are being met.
• Campbell, S., et al. (2009). "Effects of Pay for Performance on the Quality of Primary Care in England." New England Journal of Medicine 361(4): 368-378.
• Doran, T., et al. (2011). "Effect of Financial Incentives on Incentivized and Non incentivized Clinical Activities: Longitudinal Analysis of Data from the UK Quality and Outcomes Framework EDITORIAL COMMENT." Obstetrical & Gynecological Survey 66(11): 677-679.
• Steel, N. and S. Willems (2010). “Research learning from the UK Quality and Outcomes Framework: a review of existing research.” Quality in primary Care 18(2): 117-25.
• Sutcliffe, D., et al. (2012). “NICE and the Quality and Outcomes Framework (QOF) 2009-2011.” Quality in Primary Care 20(1): 47-55.
• Walker, S., et al. (2010). "Value for money and the Quality and Outcomes Framework in primary care in the UK NHS." British Journal of General Practice 60(574)

3.4. Pharmaceutical care
3.4.1. Scope of research
With respect to the pharmaceutical care, the objective of the InterQuality Project was to validate pharmaceutical benefit financing (pricing and reimbursement) models. Financing models’ effect on the quality, cost and equity of access to medicines and investment, human resources and education issues was explored and addressed. Our research consisted of comparative analysis of pharmaceutical benefit financing models, description and evaluation of pricing and reimbursement schemes, different aspects of financing access to medicines and their consequences, drug distribution models, as well as organizational, financial and regulatory aspects of Pharmaceutical Care (meant both as pharmaceutical policy and as service provided in pharmacies) in the EU partner countries (UK, Poland, Germany, Denmark, Italy) and the US. The recommended pharmaceutical benefit financing models were proposed.

3.4.2. Summary of research
Common trends in the per-capita GDPs (excluding health expenditures), per capita healthcare expenditures (excluding pharmaceutical expenditures), per-capita pharmaceutical expenditures and life expectancies of women and men aged 60 and 65 across OECD countries were analyzed. The dataset was built on the basis of OECD Health Data for 34 countries and the time period 1991-2010. Life expectancy variables were used as proxies for the health outcomes and pharmaceutical and healthcare expenditures represented drug and healthcare consumption, respectively. The results of the study indicate that there are common long-term trends in life expectancies and per-capita GDP as well as pharmaceutical and non-pharmaceutical healthcare expenditures. Available data do not allow to conclude existence of cause-effect relationship. Other factors, for which the systematic data are not available, may have determined the increase in life expectancy in OECD countries.
We performed also the systematic review of studies on catastrophic out-of-pocket spending and on assessing horizontal inequities. In respect of findings of our review not many studies on OOP catastrophic spending on healthcare have been performed in XXIth century for individual European countries. For systems like the Polish one assessing the level of catastrophic healthcare OOP spending on the base of National Statistical Office data is highly needed to monitor this sensitive problem. In the next step the pilot study on SHARE database has been performed. The database was chosen because it includes data for Germany, Denmark and Poland (starting wave 2nd) gathered in similar methodology, thus allowing for valuable comparison. Findings on catastrophic out of pocket spending on healthcare revealed that Poland is outlying two other partners with the share of households with OOP spending on health exceeding 10% of the budget as high as 24% in 2006-2007. For Germany respective number was 2.1% while in Denmark 2%. Almost 8% of Polish households in this study spent more than 20% of their income directly on healthcare, what means a real threat for their budgets and overall financial condition. Drug expenses are at the level of 96.5% of total OOP health spending in Poland in over 50 y.o. population, while 40.1% in Germany and 48.7% in Denmark.
The analysis of equity of use the healthcare services by people over 50 y.o. revealed results as below:
• In Germany statistically significant pro poor distribution of actual use of healthcare services (GP and specialists visits, but not privately paid ones, which was pro rich) changed into pro rich after standardization. Only specialist visits are equally distributed in population analysed
• In Denmark the use of physician visits in total and GP visits, when standardised for health needs gave the negative HI thus confirming statistically significant pro poor distribution. In case of specialist visits health need standardization turned out the HI from pro poor to slightly pro rich.
• In Poland for people over 50 y.o. pro rich distribution of specialist visits and physician visits in total has been revealed, and statistically significant pro rich distribution of private, paid out of pocket healthcare services use; GP actual use was pro poor. Standardization preserved all these distributions except specialist visits, which turned into slightly pro poor, almost equal. It should be however noticed that standardisation have even worsen high pro rich use of private services paid out of pocket.
On the base of findings of systematic review as well as pilot study on SHARE database the decision on performing Equity Study on national databases has been taken, with results as follow.
Our findings regarding catastrophic out of pocket spending on healthcare services, and specifically drugs, revealed high influence of health expenditure on financial condition of Polish households comparing to German and Danish ones. While in Germany in 2009 only 1.2% of households spent directly on health more than 10% of their income (or 0.1% spent more than 40% of their capacity to pay) and in Denmark in 2010 - only 3.2% of households spent directly on health more than 10% of their income (or o.8% spent more than 40% of their capacity to pay) - in Poland 2010 respective values were 23.7% and 10.3%.
Comparing health OOP spending in Poland in years 2000, 2004, 2006 and 2010 one may notice that in year 2000 relatively small percentage of households experienced the catastrophic OOPs (5.5% at the level of 5% of income through 0.1% at the level of 20% of income). However till year 2004 these measures have raised significantly reaching the level of 27.3% of households spending more than 5% of their income on health. Further growth to over 43% of households spending more than 5%, and about 9% of households spending more than 20% of the income on health took place in 2006. Since that date the percentages of catastrophic OOP health spending in Poland remains at stable level. While the structure of out of pocket spending are similar year to year the other than drug prices growth factors are drivers of the trends of catastrophic out-of-pocket health spending growth.
In Denmark the shares of households experiencing catastrophic OOP spending on healthcare were higher than in Germany (for Germany only data for 2009 are available, so trends could not be assessed) but are stable for 2000-2010 at the levels 4-5 times lower than in Poland.
In addition to high burden of OOP spending in Poland drug expenditure are concentrated with high inequity unfavourable for poor. In Denmark drug OOP spending are distributed almost equitable or slightly pro rich.
Our findings prove that the system of health spending in Denmark is stable and keeps out of pocket expenditure - and specifically drug expenditure - under control, avoiding financial catastrophe of poor households. In the same time Polish system is unstable, with quick changes which worsen financial condition of poor households. The high burden of inequities in spending on drugs overwhelms budgets of worse off citizens.
With regard to horizontal inequities in healthcare use (GP visits, hospital stays) the Danish system was found to be the most pro poor. In German system the use of hospital care displayed trend towards equal distribution while general practitioners care was rather pro rich (in some cases not statistically significant). The Polish system was proved to be highly pro rich with respect to hospital as well as in outpatient care use.
3.4.3. General conclusions
Taking into account the equity consideration conducted during our research, the progressive reimbursement system implemented in Denmark appears to be more equitable than the reimbursement systems in other countries we have studied. The pharmaceuticals reimbursement system in Denmark is considered to be more equitable as it creates a link between the level of reimbursement and the annual patient expenditures on pharmaceuticals. Therefore, our hypothesis is that progressive drugs reimbursement scheme (like the one in Denmark) should be implemented in countries with a pro-rich drugs reimbursement system (Poland). We assessed the effects of progressive reimbursement scheme implementation together with the introduction of deductibles (possibly adjusted every year caps on out-of-pocket spending on pharmaceuticals and protection mechanisms for especially vulnerable groups of patients), very wide access to pharmaceutical services in community pharmacies, implementation of e-prescribing solutions possibly supplemented by online adjudication of pharmacy claims, central register of insurance validity, as well as the current level of reimbursement and pharmacovigilance improvement on quality, cost and equity of access to medicines and investment, human resources and education issues. Effective implementation of the progressive reimbursement system (such as the one in Denmark) needs substantial investments in software and IT infrastructure. The development of IT support is costly and long-lasting and therefore should be carefully planned. Effective IT solutions translate into improvement of care and savings of time and money.
Possible implementation of the progressive reimbursement system like the one in Denmark should be preceded by the implementation of a central reimbursement register and an on-line adjudication system, whereas e-prescribing implementation would be a very good preparation.
We have tested the hypothesis that increase in pharmaceutical expenditure would cause gain in health outcomes (life expectancy) and we stated that there are many other factors which have more influence on health outcomes (life expectancy) rather than pharmaceutical (or health) expenditure and therefore solutions which lead to keeping the expenditure under control probably do not affect health outcomes in the population.
Effective management of health plans beneficiaries access to reimbursed medicines requires proper institutional set-up. The objective was to identify and recommend institutional framework of integrated pharmaceutical care, providing effective, safe and equitable access to medicines wholly or partially financed by public or private health insurance plans. The study, based on the assumptions of new institutional economics, was expected to examine and assess the functioning of the key healthcare institutions, to verify their efficiency in the resources management, as well as to analyze the institutional environment of drug policy in the United States (US), Great Britain, Poland, Italy, Denmark and Germany.
In the EU, there is a strong drive to implement selected PBM tools but little understanding that without proper institutional framework, they may not yield results comparable to the US. The key reasons are (i) diluted responsibilities, (ii) weak and sometimes conflicting motivation of different pharmaceutical sector institutions and health policy decision-makers, (iii) weak enforcement of Pricing& Reimbursement regulations. Considering the possibilities of introducing PBM tools in the EU member states, it seems that from the technical point of view, partial or total implementation would be feasible in the foreseeable future but achievement of comparable outcomes would not be realistic without comparable institutional framework.
• Małgorzata Chmielewska, Marcin Czech, Tomasz Faluta, Agnieszka Gadaj, Tomasz Hermanowski, Aleksandra Kiljan, Marta Kowalczyk, Agnieszka Prokurat, Izabela Sakowska, Sylwia Szafraniec‐Buryło. Measuring Quality, Equity, Outcomes and Efficiency in Pharmaceutical Care. Feb‐Nov 2011. International Research on Financing Quality in Healthcare, InterQuality Project (Grant Agreement 261369) Values/Benefits Project Periodic Report (WP2); Collaborative Work SPH for WP2
• Małgorzata Chmielewska, Marcin Czech, Aleksandra Drozdowska, Tomasz Faluta, Tomasz Hermanowski, Aleksandra Kiljan, Szymon Zawodnik. Financing Methods for Pharmaceuticals. October 2011. International Research on Financing Quality in Healthcare, InterQuality Project (Grant Agreement 261369) Collaborative Work SPH for WP1
• Tomasz Hermanowski, Małgorzata Chmielewska, Urszula Cegłowska, Aleksandra Drozdowska, Dominika Dulęba, Aleksandra Kiljan, Marta Kowalczyk, Aleksandra N. Krancberg, Sylwia I. Szafraniec‐Buryło, Andrzej Szczypior, Zbigniew Tytko. Deliverable 3.1. Report on Financing Pharmaceutical Care. Version 0.5 03/10/2013. International Research on Financing Quality in Healthcare, InterQuality Project (Grant Agreement 261369) Final Report
• Tomasz Hermanowski, Victor Bystrov, Urszula Cegłowska, Małgorzata Chmielewska, Dominika Dulęba, Katarzyna Kolasa, Aleksandra N. Krancberg, Christian Kronborg, Jørgen T. Lauridsen, Ewa Orlewska, Daniel Rabczenko, Tomasz Rybnik, Anna Straszewska‐Bystrova, Sylwia I. Szafraniec‐Buryło,Andrzej Szczypior, Zbigniew Tytko, Anna Zawada. Deliverable 3.2. Report on Recommended Financing Models. Version 8.0 23/12/2013. International Research on Financing Quality in Healthcare, InterQuality Project (Grant Agreement 261369) Final Report
• Availability and quality of data on pharmaceutical benefit financing components of health care system in United States, United Kingdom, Denmark, Germany, Italy and Poland, Hermanowski T, Szafraniec-Burylo S, Cegłowska U, Drozdowska A, Dulęba D, Kowalczyk M, Krancberg AN, Pashos CL, Szczypior A, Chmielwska M, Czech M, Poster presentation on 13th International Conference on Integrated Care, Berlin, Germany, April 11-12, 2013, Int J Integr Care 2013; Annual Conf Suppl; URN:NBN:NL:UI:10-1-114676
• Measuring quality, equity, outcomes and efficiency in pharmaceutical care as a part of managed care, Hermanowski T, Pashos CL, Szafraniec-Burylo S, Krancberg AN, Kowalczyk M, Chmielwska M, Czech M; Oral presentation on 13th iInternational Conference on Integrated Care, Berlin, Germany, April 11-12, 2013, Int J Integr Care 2013; Int J Integr Care 2013; Annual Conf Suppl; URN:NBN:NL:UI:10-1-114662
• Models of Drug Safety Monitoring in England, Poland, Italy, Germany, Denmark and United States, T.R. Hermanowski, A.N. Krancberg, S.I. Szafraniec-Burylo, ISPOR 16th Annual European Congress, 2-6 November 2013, Dublin, Ireland, Value in Health November 2013 (Vol. 16, Issue 7, Page A463)
• Current Status and Evidence of Effects of E-Prescribing Implementation in United Kingdom, Italy, Germany, Denmark, Poland and United States, T.R. Hermanowski, M. Kowalczyk, S.I. Szafraniec-Burylo, A.N. Krancberg, C.L. Pashos, ISPOR 16th Annual European Congress, 2-6 November 2013, Dublin, Ireland, Value in Health November 2013 (Vol. 16, Issue 7, Pages A462-A463)
• Specific Attributes of Pharmaceutical Care in England, Poland, Germany, Denmark, Italy and United States, T.R. Hermanowski, D. Duleba, A.N. Krancberg, S.I. Szafraniec-Burylo, C.L. Pashos, ISPOR 16th Annual European Congress, 2-6 November 2013, Dublin, Ireland, Value in Health November 2013 ( Vol. 16, Issue 7, Page A463
• Availability and quality of data on drug policy and management of access to reimbursed medicinal products in the United Kingdom, Denmark, Germany, Italy and Poland; Hermanowski T, Szafraniec-Buryło SI, Krancberg AN, Dulęba D, Cegłowska U; Zeszyty Naukowe Ochrony Zdrowia. Zdrowie Publiczne i Zarządzanie (w druku, numer 1-2/2013)
• Wpływ wydatków typu out-of-pocket na sprawiedliwość w finansowaniu ochrony zdrowia; Hermanowski T, Szafraniec-Burylo SI, Cegłowska U, Zeszyty Naukowe Ochrony Zdrowia. Zdrowie Publiczne i Zarządzanie (w druku, numer 1-2/2013)
• Pharmacotherapy management in integrated care in Europe; Hermanowski T, Szafraniec-Buryło SI, Krancberg AN, Cegłowska U, Orlewska E. International Journal of Integrated Care (wysłana do druku)
• Danish healthcare information technology network reform as a model solution for pharmaceutical care integration in other countries; Hermanowski T, Szafraniec-Buryło SI, Cegłowska U, Krancberg AN, Orlewska E, International Journal of Integrated Care (wysłana do druku)
• O’Donnell O, et al. (2008). Analyzing health equity using household survey data: a guide to techniques and their implementation. The World Bank.
• Wagstaff A, et al. (2003). On decomposing the causes of health sector inequalities with an application to malnutrition inequalities in Vietnam. J Econ 112:207–23.
• van Doorslaer E, et al. (2000). Equity in the delivery of health care in Europe and the US. Journal of
• Health Economics 19:553–583.
• van Doorslaer E., et al. (2004a). Income-Related Inequality in the Use of Medical Care in 21 OECD
• van Doorslaer E, et al.(2004b). Explaining income-related inequalities in doctor utilisation in Europe. Health Econ. 13: 629–647
• van Doorslaer E, et al.(2006). Inequalities in access to medical care by income in developed countries. Canadian Medical Association. Journal; Jan 17, 174, 2.
• Xu K, et al. (2003). Household catastrophic health expenditure: A multicountry analysis. The Lancet 362:111.
• Xu K, et al. (2007). Protecting Households From Catastrophic Health Spending, Health Affairs, 26(4):972- 983.
• Xu K, et al. (2010) Exploring the thresholds of health expenditure for protection against financial risk. World Health Report, Background Paper
• Statistics Denmark
• German Socio Economic Panel (SOEP)
• GUS, Central Statistical Office in Poland
• SHARE - Survey of Health, Ageing and Retirement in Europe
• Kolasa K, Rybnik T., [Socio-demographic determinants of inequity of access to health care in Poland in 2011--based on social diagnosis]. Przegl. Epidemiol., 2012;66(4): 681-688 (in Polish)
• Luczak J, Garcia-Luczak J, Garcia-Gomez P. Financial burden of drug expenditures in Poland. Health Policy, 2012;105(2-3): 256-264

3.5. Integrated care
3.5.1. Scope of research
Hardly any topic dominates the international discussion platform like the debate on integrated care does. Integrated care encompassed the systematic design of healthcare processes across different sectors and professional guilds. The greatest challenge in the design of healthcare systems is the optimization of the communication between and the coordination of activities of different healthcare providers. The need to optimize care for chronic and mostly multi-morbid patients presents the most significant challenge in the design of modern healthcare systems. The integration of care across existing boundaries increasingly presents a key challenge. The complexity in this regard is not the optimization of the individual unit services, but the interaction of different providers in coordinated healthcare delivery processes (for instance in the form of disease management programs). Integrated healthcare represents an ideal type of selective contracting that requires the search and engagement of appropriate partners as well as the implementation of incentive structures such as P4P.
3.5.2. Criteria development: Risk-Adjustment
The objective of risk adjustment is to generate and provide information about risks of morbidity and risk factors within a specific population group as well as on crucial weights in risk adjustment. Based on the obtained risk structure the expected utilization as well as its costs in future periods shall be predicted. Accountable care organizations (ACOs) in the US and similar concepts in other countries are advocated as an effective method of improving the performance of healthcare systems [1]. ACOs outline a payment and care delivery model that intends to tie provider reimbursements to predefined quality metrics. By this the total costs of care shall be reduced [2].
Systematic literature review on methods of risk adjustment was conducted in terms of an encompassing, interdisciplinary examination of the related disciplines. In general, several distinctions can be made: in terms of risk horizons, in terms of risk factors or in terms of the combination of indicators included. Within these another differentiation by three levels seems reasonable: methods based on mortality risks, methods based on morbidity risks as well as those based on information on (self-reported) health status. In total seven (disease-specific) mortality risk scores, eight scores based on pharmaceutical information (including Chronic Disease Score, Rx Groups, PCG: Pharmacy-based Cost Groups and DxCG Rx Groups) have been identified[3]. Additionally 11 main risk adjustment methods based on diagnostic information were detected as well as several derivatives, accounting for 18 different risk adjustment mechanisms. After the final examination of different methods of risk adjustment it was shown that the methodology used to risk adjust varies and that it differs greatly in terms of their included morbidity indicators.
Looking at the results of the literature review it seems to be reasonable to make a differentiation by three levels:
• Risk adjustment with information on individual person (age, sex, ethnical group, disability etc.),
• Risk adjustment with information on utilization (ACG, DCG, DCG/HCC, PIP-DCG, AAPCC, CDPS-Rx, CMS- HCC, PCG, etc.) and
• Risk adjustment with information on health status.
The basic principle of risk adjustment is to identify the crucial health risks, and to compare the various groups of insured persons to forecast their future costs and utilization for health services.
3.5.3. Pay for Performance
Numerous studies have revealed that many healthcare systems can be characterized by ineffective-ness and inefficiency for example because of the payment system of healthcare providers [5-7]. One approach to improve the quality of healthcare that has become increasingly popular is Pay-for-Performance (P4P). P4P links payments to performance on predefined quality measures [8]. This analysis aims at assessing P4Ps effectiveness. In addition success factors that need to be regarded when designing and implementing prospective P4P programs are identified. A systematic literature search on P4P-reviews was conducted 75 different primary studies were analyzed. The analysis identified that the structure of P4P programs contains of three essential components:
• Quality indicators: Most P4P programs measure a combination of process and outcome indicator.
• Beneficiary level: Incentives mainly focus on individuals,
• Design of the financial incentive: Almost all programs use rewards, the amount of incentive varies between <2% and 25% of total reimbursement, payments are mostly based on absolute thresholds, frequency and duration are rarely analyzed.
Reviews confirm that P4P can improve the quality of care, though not always. Therefore, financial incentives have to be designed and implemented carefully. The success of P4P depends on the appropriateness of structure of a P4P program (three components). Consequently, P4P programs have to be developed by both payers and physicians. The influence of unintended consequences and public reporting has to be considered as well.
3.5.4. Contract Design
A healthcare contract is a relational contract, which determines the level of reimbursement, the scope of services and the quality between service providers and payers, taking account of the risks relating to population and performance. A relational contract is an agreement based upon assumption of a longer timeframe.[9,10] Upon conclusion of the contract only a framework is agreed, the specific details are only finalized over the course of the agreed contractual period. Healthcare contracting between providers and payers will have a major impact on the overall design of future healthcare systems.[1]
The risk structure of the providers plays a vital role in Pay for Performance. A prerequisite for optimal incentive-based service models is a (partial) dependence of the agent’s returns on the provider’s gain level. Accountable care organizations (ACOs) in the US and similar concepts in other countries are advocated as an effective method of improving the performance of healthcare systems. ACOs outline a payment and care delivery model that intends to tie provider reimbursements to predefined quality metrics. By this the total costs of care shall be reduced.
Little is known about the contractual design and the main challenges of delegating “accountability” to these new kinds of organizations and/or contracts. The costs of market utilization are highly relevant for the conception of healthcare contracts; furthermore information asymmetries and contract-specific investments are an obstacle to the efficient operation of ACOs. The research question in this part of the project focuses on how reimbursement strategies (especially Pay for Performance), evaluation of measures and methods of risk adjustment can best be integrated in healthcare contracting.
New institutional economics [11-14] provides sufficient points of reference to enable the discussion of the problems of healthcare contracts. An in depth theoretically analysis of contractual designs is required to successfully design this new kind of contracts and to avoid pitfalls. Healthcare contracting between providers and payers will have a major impact on the overall design of future healthcare systems [1]. A major obstacle to the practical implementation of healthcare contracts is the prognosis of the inflows and outflows due to the actuarial risks of the insured population. Financing conditions and reimbursement arrangements that are based on a prospectively determined fixed price, have a significant drawback: it is very difficult to take the differences in health status and the utilization of distinct insured clientele (panel) into account. In the future selective individual contracts will be completed in a competitive procurement process. Potential provider are identified and invited to tender. In the sense of solution options of information asymmetries prior to concluding detailed bids will be requested (screening), certificates on evaluations and external quality management measures will be sifted (signalling), several agreements for the purpose of self-selection by the health insurance will be put forward (self-selection) and offers will be evaluated regarding the trustworthiness (reputation). So that market forces can produce efficient allocation on the market for healthcare reimbursement contracts, the care provider need to state how they plan to guarantee the desired quality at an appropriate price-performance ratio (cost-effectiveness) for a specific population over a given period before signing a contract. Health insurance companies and care providers must be able to organize this process. If the findings of the principal-agent theory and the solution options are implemented in the practice, the existing information asymmetries can be reduced and the objectives of the parties harmonized. If long-term cooperation relations should facilitate efficient cooperation, trust must be established between the parties.

3.5.5. Patient education
Chronic diseases like cardiovascular diseases, diabetes and asthma or chronic obstructive pulmonary disease are the leading cause of mortality and morbidity in Europe and will impose an even greater burden in the future. This part of the EU-Project addresses the effectiveness, accessibility and quality in patient education programs for patients with type 2 diabetes mellitus and children with bronchial asthma. To approach the research question three metropolitan areas in Europe were selected: London, Warsaw and Berlin. Education for people with chronic diseases aims to improve their knowledge and skills, enabling them to take control of their own condition and to integrate self-management into their daily lives. Patient education or self-management can be described as a measure to assist patients in changing their behavior in such a way that it minimizes restrictions or makes the chronic disease more manageable [15].
The empirical analysis is based on the assumption that there are differences in the provision of educational programs for type 2 diabetes and asthma in the three selected metropolises. An extensive literature search of patient education in the respective countries helped at identifying the relevant quality indicators (quality, access and efficiency) of patient education. Based on this list of quality indicators, a questionnaire for conducting the expert interviews was developed. For analyzing the open-ended questions a qualitative content analysis according to Mayring was conducted. The different categories, to which the answers were assigned, were counted and weighted for being able to illustrate and interpret the results. Additionally, to support the qualitative analysis, a mind mapping was conducted [16].
The implementation of the patient education programs as well as the basic conditions for implementing educational programs vary considerably in the cities of Warsaw, Berlin and London. Patient education can be offered within two different settings in Berlin (Germany), the Disease Management Programs (DMPs) or as complementary services within medical rehabilitation. If the patient education program is offered within the DMP the providers must follow implementation guidelines. Expenses are reimbursed by the statutory health insurance. Within the DMPs, education is only provided in the outpatient setting, whereas in medical rehabilitation it can be provided either in the inpatient setting or in day hospitals.
In London (United Kingdom) there are no mandatory regulations for the implementation of patient education programs. However, the NICE issues guidelines and recommendations which serve as a basis for most of the programs. The NHS finances patient education programs and Patients do not have to pay any co-payments. Education for type 2 diabetes is provided in the outpatient setting whereas education for asthmatic children is predominantly provided in hospitals after an acute attack.
Legal provisions for the implementation of patient education programs also do not exist in Warsaw (Poland). Non-profit organizations such as the Polish Diabetes Association issue guidelines for the implementation of educational programs and finance the programs in cooperation with pharmaceutical companies. The educational programs can also be provided both within the outpatient and the inpatient setting.
In all of the cities both active and passive approaches are used to draw the patients’ attention to the programs. While in Berlin and London personal conversation with physicians is the most common means of information, in Warsaw, the most important means of information are word-to-mouth recommendations of patients. The use of posters and brochures as well as the internet represent the passive approach used in all cities.
1. Mühlbacher, A., Amelung, A., Juhnke, C. (2014): Contract Design: What should healthcare contracts look like? In: International Journal of Integrated Care (submitted)
2. Marcus, S.G. K.M. Reid-Lombardo, A.L. Halverson, V. Maker, A. Demetriou, J.E. Fischer, D. Bentrem, M. Rudnicki, J.R. Hiatt, and D. Jones, Staying Alive: Strategies for Accountable Health Care. Journal of Gastrointestinal Surgery, 2012: p. 1-8.
3. Juhnke, C., Bethge, S., Mühlbacher, A. (2014): A review on methods of risk adjustment and their use in integrated healthcare systems. In: International Journal of Integrated Care (submitted)
4. Erler, A., M. Beyer, C. Muth, F. Gerlach, and R. Brennecke, Garbage in-Garbage out? Validität von Abrechnungsdiagnosen in hausärztlichen Praxen Garbage in-Garbage out? Validity of Coded Diagnoses from GP Claims Records. Gesundheitswesen, 2009, 71(12): p. 823-831.
5. McGlynn EA, Asch SM, Adams J, Keesey J, Hicks J, DeCristofaro A, Kerr EA (2003): The Quality of Health Care Delivered to Adults in the United States, New England Journal of Medicine, 348, 2635-45.
6. Wennberg J (2011): Time to tackle unwarranted variations in practice, BMJ, 342, 687-690.
7. Institute of Medicine (2001): Crossing the Quality Chasm: A New Health System for the 21st Century, National Academy Press, Washington DC.
8. Roland M (2004): Linking Physicians´ Pay to the Quality of Care – A Major Experiment in the United Kingdom, New England Journal of Medicine, 351 (14), 1448-1454.
9. MacNeil, I.R. Many Futures of Contracts, The. S. Cal. L. Rev., 1973. 47: p. 691.
10. MacNeil, I.R. Contracts: adjustment of long-term economic relations under classical, neoclassical, and relational contract law. Nw. UL Rev., 1977. 72: p. 854.
11. Alchian, A.A. and H. Demsetz, Production, information costs, and economic organization. The American Economic Review, 1972, 62(5): p. 777-795.
12. Jensen, M.C. and W.H. Meckling, Theory of the firm: Managerial behavior, agency costs and ownership structure. Journal of financial economics, 1976, 3(4): p. 305-360.
13. North, D.C. Institutions, institutional change, and economic performance. 1990: Cambridge Univ Pr.
14. Richter, R. and E.G. Furubotn, Neue Institutionenökonomik: Eine Einführung und kritische Würdigung. 2003: Mohr Siebeck.
15. Faller, H., A. Reusch, et al. (2005). "[Patient education]." Die Rehabilitation 44(5): 277-286.
16. Mayring, P. (1997). „Ex-ante Hypothesen in der qualitativen Sozialforschung: Zwischen ‚fehl am Platz‘ und ‚unverzichtbar‘“ Zeitschrift für Soziologie, 26(1):22-34.
17. Schone, E. and R. Brown, Risk Adjustment: What is the Current State of the Art and how can it be Improved? 2013, Robert Wood Johnson Foundation: Princeton.
18. Penner, S.J. Introduction to health care economics and financial management. Fundamental concepts with practical applications. 2004, Philadelphia, Pa. [u.a.]: Lippincott Williams & Wilkins. XII, 323 S.

3.6. Communication strategy for innovative health care financing models
Once an appropriate model for the financing of healthcare services has been identified, policy-makers face the task of translating it to real-life practice through a healthcare reform. Given the complexity of healthcare policy and the number of stakeholders involved, the negotiation and implementation of healthcare financing reforms can be significantly affected by political opposition, public opinion, and key stakeholders’ positions. If a lack of support for the reform is sustained, it endangers the effective implementation and thus the benefits expected of the financing model therein. To overcome these barriers, real dialogue meaning effective communication and involvement of all parties in preparing decisions at all stages of the process are crucial. These guidelines for healthcare financing reforms communication strategies aim to a) establish a baseline for reform communication and b) review real-life reforms as case studies. On this basis, recommendations are compiled to act as communication guidelines.
The baseline for reform communication was constructed with the help of a literature review of publications on theoretical and practice-based analyses of reform communication. By way of theoretical background, the concepts of ‘strategic communication’ and ‘knowledge management’ were discussed with a view to establishing a rationale for healthcare reform communication. While little research currently exists on communication strategies for reforms to healthcare systems in specific, publications on public governance reform, public health communication and social welfare reform were also taken into account. These sources were then evaluated as to recommendations. All recommendations identified thus were compiled in matrix which was later discussed against the background of the case studies’ findings.
To complement the outcomes of the literature review the research next focussed on real-life reforms which were analysed. On the basis of their contextual communication activities, reforms in Poland (1999), Germany (2004) and the USA (2010) were selected as case studies. These case studies were analysed as to the overall reform context, the specific communication strategy in terms of target audience and communication tools and channels used. The analysis also looked at the activities of key stakeholders, such as patients and doctors (and other health care professionals), and the general public in reaction to the communication campaigns. The case studies were carried out on the basis of desk research for primary and secondary literature on the reforms’ communication strategies. As suited to the case studies’ respective political and temporal contexts, additional tools such as online media and social media were also taken into account. In addition, a number of focussed interviews were carried out with experts on the respective reform.
The case studies established the relative strengths and weaknesses of each reform’s communication strategy. The analysis showed the importance of political support for and investment in communication of healthcare reforms, with insufficient commitment creating negative repercussions for the negotiation of the reform and its implementation. The case studies showed that the clear identification of a target audience and campaign messages was often neglected and information was disseminated ineffectively. The involvement of stakeholders in the decision-making process was shown to be key to the effectiveness of the communication strategy. Also, the specific national political and socio-economic context, as well as communication culture, was demonstrated to have significant impact.
In a final step, the case studies were compared against the matrix of recommendations resulting from the literature review. The recommendations were consolidated to enshrine the case studies’ outcomes and ensure results had relevance to real-life reforms. The following recommendations were identified:
Objectives of the communication strategy
• Consult all the stakeholders from the very beginning of the reform planning about their views and ideas for discussion
• Address the gaps in the knowledge of the target audience which prevent them from adopting the desired behaviour
• Improve the sustainability of the reform’s success by fostering two-way communication (e.g. organisation of public question and answer sessions, organisation of consultations to illustrate opportunities for engagement and encourage ownership)
• Improve the success of the communication strategy by improving literacy of audience in subject matter (e.g. dissemination of also information that is not specifically linked to the objectives of the communication strategy)
Target Audience
• Identify the audience of the communication strategy (e.g. stakeholders, sub-categories of target audience, with special emphasis on patients and the medical profession and its representative organisations)
• Identify the allies, opposition and ‘hard-to-reach’ audience at the start of the campaign
• Define a clear campaign message
• Tailor the campaign message to different audiences
• Identify the existing communication/dialogue infrastructure
• Introduce new communication channels for the communication strategy if necessary
• Coordinate public and private communication channels
• Use specific strategies to reach the ’hard-to-reach’ audiences
• Define the volume of financial resources that can be budgeted for the consultation and communication strategy
• Define the staff capacity and expertise necessary to execute the strategy
• Define the type and volume of external expertise necessary to execute the strategy
• Weigh the budget in terms of the dialogue and communication channels planned to be used

Monitoring and evaluation
• Identify the barriers to the implementation of the consultation and communication strategy
• Review the strategy during the campaign
• Add or remove elements to/from the strategy during the campaign if necessary

Impact Assessment
• Assess the impact of the consultation and communication strategy
• Assess whether the goals of the strategy were attained

Standing Committe of European Doctors, Communication Guidelines. Healthcare Financing Reforms Communication Strategies, International Research on Financing Quality in Healthcare, InterQuality Project (Grant Agreement 261369)
Potential Impact:
The results of InterQuality Project have significant and direct applications to actual healthcare systems, not only in the countries represented in the Consortium but also the other European systems. Our research has advanced the state-of-the-art by considering deeply the role of the main features of the context in affecting the incentives associated with different financing methods. The results of investigation conducted will be considered a valued reference point, thanks to the unique laboratory of financing systems in hospital sector represented by the Italian NHS and in-depth analysis of UK Quality and Outcomes Framework as the best published evidence on outpatient care.
With regard to the reimbursement systems InterQuality Project points out some promising solutions already implemented in partner European countries and the US. Main direction of changes needed for implementation of the recommended pharmaceutical benefit financing model are indicated.
InterQuality Project also gives new insight into crucial problems affecting integration of healthcare sectors. The healthcare systems worldwide are highly fragmented. They are constructed in a silo structure and each of the silos, again, is fragmented. The different sectors, inpatient, outpatient and rehabilitation, the different healthcare provider structures, primary care and secondary care, and the different professions, physicians and nurses, do not work jointly together but have a very distinct and separate range of tasks. However, the patient entering a healthcare system does not wish to be confronted with these distinct sectors and professions, but rather expects an integrated and comprehensive treatment, encompassing all sectors and all professions.
Integrated care can help overcoming these barriers between the different sectors, structures and professions. However, even though the concept of an integrated healthcare system may seem compelling, the international evidence for integrated care is still limited. Only very few studies were able to proof the benefits of integrated care as compared to standard care. The objective was therefore to create the necessary transparency in order to show which concepts and components of integrated care could and should be implemented. We indicate how health care concepts should be established in order to enhance the quality of care.
The quality of care can strongly be influenced by performance-based payment systems such as pay-for-performance (P4P). In P4P, the achievement of a predefined quality level is financially rewarded. Just as in integrated care, intuitively, this payment model seems to be highly desirable. Even though P4P can help to enhance the quality of care, it may also lead to unintended consequences. In order to successfully implement P4P, it is necessary to align physicians’ preferences with the indicators chosen for the payment scheme.
The project has shown that complete contracts in healthcare are unrealistic. Healthcare reimbursement contracts are incomplete contracts with a high degree of uncertainty. In incomplete contracts specific contractual regulations are not made for any eventuality. For this reason it is important that the parties agree on the prevention of endogenous risks (asymmetric information after the conclusion of the contract) and on the procedure in the case of unforeseen circumstances (the risks of random, parameter risk and change risks to the healthcare program). It is also not possible to integrate all potential risks in the contract or to eliminate these risks by the parties. To control these risks, healthcare providers/payers should provide reimbursement contracts that include structured models for renegotiation and risk sharing/shared-savings. However, it is not advisable to allow an agreement to renegotiate individually for each risk event. It is therefore important to ensure ex ante that the contract clearly states the circumstances (risk events), which are authorized under renegotiation. Moreover, it must be noted, who bears the risks as well as the potential shares of risks, the contracting parties shall bear.
Rawls definition of ‘social justice’ is about assuring the protection of equal access to rights and opportunities for health and fulfilling lives. Issues related to equity of access and financing of healthcare, which were carefully examined by Work Package 3 “Pharmaceutical care”, are definitely included in this definition. Studies on equity in healthcare, which were conducted during the empirical phase of the project, revealed that the progressive reimbursement system implemented in Denmark appears to be more equitable than the reimbursement systems in other countries included in comparative analysis, namely Germany and Poland. The health policy decision-makers will need to take a broader view on equity when deciding on how much of the resources to set aside for health and how best use those resources. Thus, our recommendations might be useful in this context. Health may also affect the economic performance of communities through its impacts on demographic factors, such as life-expectancy. The relationship between the expenditures on pharmaceuticals and the life-expectancy was also investigated. However, the results show that there are many other factors which have more influence on health life expectancy rather than pharmaceutical expenditure .In general, the findings of the Project can be used in the evaluation of integrated/ organized healthcare delivery systems and can be integrated into quality- and patient-oriented reimbursement of care provided in the design of healthcare contracts to promote better health care delivery. Organizations that already have moved forward in contracting and have transformed into some form of an accountable care organization will need to assess their contracts and adjust their operations, processes and monetary and quality metrics in accordance to their participants. These transformations will take time because of the complexity and potential cost of meeting the proposed requirements. But finally this could help to ensure a better health care delivery for all health care systems and their people concerned.
InterQuality researchers made also an attempt to evaluate the effectiveness of patient education programs in an innovative study design. Rather than comparing entire countries with each other, metropolitan areas were compared instead. Both the living conditions and the availability of healthcare providers resemble each other more strongly when comparable cities are chosen than when a comparison of entire states is conducted. Both the structure and the impact of patient education in Berlin, London and Warsaw were highlighted by conducting reviews and expert interviews. Recommended actions on how to improve existing patient education programs or how to establish new programs can be derived from the research.
As demonstrated in the analysis of healthcare financing reforms consultation and communication strategies , the lack of a consultation and communication strategy or the ineffective application of a strategy can lead to significant delays and barriers to the political negotiations towards a reform and its implementation. One of the key factors is the effective involvement of key stakeholders whose opinion also acts as a reference point for other actors. Insufficient political will or a lack of resources can therefore have economic consequences, including opportunity costs, resulting from possible belated or incomplete implementation of reforms into practice. Given the relative lack of existing studies dealing with consultation and communication for reforms to healthcare (financing) systems, the findings could be helpful for the target audience, particularly governments and public authorities, civil society stakeholders and academia.
In accordance to the spirit of the “Seventh Framework Programme”, the dissemination of InterQuality results is an essential part of the project. The research products generated in the Project already have got, and will have more in the future, an important scientific impact in the academic field, by contributing to the international literature. The important part of our dissemination activity is represented by the publication of research products in international scientific journals, as well as the dissemination of our results in conferences and seminars with academic audience.
So far, a large amount of recommendations for health care system improvement have been produced by InterQuality work packages. The recommendations are published in Policy Briefs, which are available on the project website ( Those publications are aimed at government policymakers or others who are interested in formulating or influencing health policy. The IQ Policy Briefs might be a useful tools for conveying the implications of scientific evidence for policy and practice.
Thus far, several articles have been published in English-language, peer-reviewed scientific journal with impact factor (IF) that publishes original articles in the field of health policy, public economics, social science and integrated health care. Publishing in English will increase citation counts and thus IF and therefore the IQ results will be accessible to a much wider audience. Besides, several more articles have already status submitted. Some articles were also published in national journals intended for professionals and researchers in all fields of health care. Moreover, number of abstracts have been already submitted and presented on various national and international conferences in the field of health economics and health policy.
The major results of Work Packge 2 ‘Values/Benefits’ will be published as textbook ‘Measuring and Financing Quality in Healthcare’. The textbook will be dedicated for students and young researcher in order to acquaint them with the concepts of quality measurement and financing in healthcare.
The textbook also seeks to explain methodological challenges facing international comparative research, attempt to develop consensus on common terminology and conceptual framework for measurement of the quality, outcomes, costs, efficiency and equity in healthcare systems.
The research conducted in the project will have wider societal implications. Our results have provided new knowledge concerning the effects of financing methods in healthcare, addressing public decision-makers toward a smarter way to design payment systems. Accordingly, this new knowledge could potentially generate a considerable saving of financial resources, reducing the excessive burden of healthcare costs in the national budgets. To this extent, our project will have an significant socio-economic impact, considering also the recent public discussion on the economic sustainability of healthcare systems in many OECD countries. On the other hand, part of the cost saving generated by a more efficient and appropriate provision could be reinvested to enhance the overall quality of medical services. Regardless the cost saving, the improvement in the quality of services represents an invaluable impact of our research, implying an overall increase in the aggregate social welfare.
Good health is essential for human well-being, social and economic development and therefore it should be recognized as a fundamental social goal. Health is an asset, a component of what economists define as ‘human capital’. Good health raises human capital levels and therefore the economic productivity of individuals and a country`s economic growth rate. Thus, governments need to invest resources in healthcare in order to raise the health status of their citizens. A key marker of the successful healthcare system is the extent to which it facilitates the delivery of efficient, effective and equitable care. However, taking into account that the resources are limited and the demand for healthcare resources will necessarily exceed supply, allocation becomes a problem. The InterQuality project tried to find a possible solutions for this problem by investigating the impact of financial payment mechanisms on quality, effectiveness, costs and equity in healthcare and considered how they are affected by relevant features of health care systems
In conclusion, the InterQuality project will make a substantial contribution to ongoing debate on potential trade-offs between cost-efficiency and quality of care. In particular, the results of the project will lead to more efficient allocation of healthcare resources and to better quality of care, achieved by spending not more but smarter.

List of Websites:

Project Leader- Prof. dr hab. Tomasz Hermanowski; mobile: +48 797 602 613; email:
Project Manager- Jakub Rutkowski; mobile: +48 797 602 615; email:

InterQuality Project Office
Department of Pharmacoeconomics
Medical University of Warsaw
81 Żwirki i Wigury Ave.
02-091 Warsaw, Poland