Quality-based payment: six case examples

The logic of paying more for high-quality care and less for low-quality resonates. Increasingly health system leaders worldwide acknowledge that payment reforms are needed to do just that, prompted no doubt by the growing body of evidence indicating that quality is not what it should be.

This review was undertaken to explore contexts in which quality-based payment appears feasible. The ultimate intent is to provoke thoughtful debate about whether and how quality-based payment might fit within a particular developing country's framework of policies to ensure and promote quality of care.

With guidance from key informants with first-hand knowledge of international quality-based payment schemes, a purposive sample of six quality-based payment schemes was assembled. Schemes were examined to identify environmental contexts and design features.

Examples illustrate a variety of approaches and a breadth of contexts in which quality-based payment has been implemented. Contrary to what might be expected, implementation does not appear to be constrained to private-sector purchasers, private-sector providers, hospital settings, nor to any particular type of underlying payment system. Further, quality-based payment pioneers are using a variety of incentive structures, and are tapping a rich mix of structural, process, and outcome standards to benchmark quality.

Despite significant operational challenges, quality-based payment has been implemented in developing as well as developed countries, albeit not frequently in either instance. What we do not know--what the literature is nearly silent on--relates to the sustainability and ultimate impact of alternative incentive schemes.