ISQUA16-3191 What Can Be Learned from the Implementation of a Pay for Performance Programme?

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ObjectivesIn France, quality indicators have been compulsory for acute care hospitals since 2008. After a decade of public reporting, the context was favorable to the introduction of a pay for performance scheme. Indeed, the French hospitals financing model, based on DRGs, has not been taking quality into account. A financial incentive based on results on quality dimensions could be a tool to promote quality of care.MethodsA research program named IFAQ was launched in 2012. The steering committee was co-chaired by the Ministry of health and the French National Authority for Health. A working group was set up, with experts appointed by hospital representatives, to specify the model. An independent research team was selected to act as scientific advisor. The objective was to develop a national P4P program (metrics, incentive model and incentive size), to evaluate its effects and the appropriation by the professionals.The Ministry of Health launched a call for application in June 2012. Out of 450 hospitals, a panel of 222 hospitals was randomly selected for the first experimentation which ended in December 2014. A second call for application was launched in June 2014 and 490 hospitals were included in the second phase which ended in December 2015.The guiding principles of the program were to develop a composite score able to discriminate hospitals, to reward both achievement and improvement in quality, to ensure consistency with other policies regarding quality of care, to limit the workload for the hospitals, and to use only positive incentive without financial penalty. Furthermore, financial incentive was conditional upon the accreditation results (minimal level) and upon the collection of needed data to calculate quality indicatorsResultsThe lessons learned from experimentation are : first, the relatively small size of financial incentive was however a powerful argument and generate interest; second, the score had a good discriminative power even if for a few small hospitals it was questionable because of unavailability of some indicators ; third, when using a single composite score, it is difficult to individualize the contribution of achievement and improvement in the final score; finally, the calculation formula was too complex to be easily communicated and to permit teams to take this challenge on boardAs a result, the final model links incentive payments to 52 nationally defined compulsory measures addressing process of care, including compliance with clinical guidelines for specific diseases such as myocardial infarction, level of computerization and patient experience. The weights have been revised and range from 1 to 3. Two composite scores are calculated for every eligible hospital: one for the achievement score and the other on improvement. Hospitals are ranked and the top performers (first two deciles) for each score are rewarded. The financial reward is a function of the rank and the hospital budget. Hospitals could potentially earn a maximum of 1.2% of their annual DRGs based payments by the health insurance funds.ConclusionThis type of program was considered by all stakeholders as a model of co-management which led to a better acceptability and to an easier implementation. The 2015 Social Security Finance act enacted the extension of this quality incentive model to every acute care hospital in 2016. One third of them are expected to receive a financial reward in December for a total amounting to 40 million Euros