How to further develop quality competition in the German healthcare system? Results of a Delphi expert study

Many international healthcare systems use quality competition to improve the quality of care. The corresponding instruments include quality measurement, public reporting, selective contracting, and pay for performance. The German healthcare system clearly shows that the possibilities are often limited in the status quo. Therefore, a need for practicable and evidence-based proposals are necessary to further the development of quality competition.

We conducted a national analysis and an international comparison (Switzerland, Netherlands and USA) as a pre-study to derive recommendations. On this basis, we designed a Delphi study with a consensus objective. Experts from relevant stakeholder groups in the German healthcare system were selected using purposive sampling for this study.

The experts saw potential for quality improvement in the further development of quality competition. Quality measurement and public reporting were rated as empowering tools. There was mostly disagreement on whether quality competition should be further developed in a more regulatory or entrepreneur-based manner. However, there was a clear consensus that further development must be coordinated between the stakeholders, step-by-step and scientifically supported. In addition, the impulse should be supported by a legislatively introduced reform.

Finally, these empirically based recommendations highlight the need for a coordinated coexistence of a top-down and a bottom-up approach. The developed blueprint proposal serves as an impetus for practical considerations of implementation.