Article information
Resumen
El concepto de «pago por calidad» (P4P) reúne un conjunto de diferentes estrategias que intentan estimular la mejora de la calidad asistencial remunerando a los proveedores de atención sanitaria según sus resultados en el cumplimiento de objetivos de calidad o productividad predefinidos. Pese a que la efectividad del P4P para mejorar la calidad de la atención está poco establecida, estos sistemas se están difundiendo ampliamente en el Reino Unido, Estados Unidos y otros países, incluida España. Los elementos del diseño de los esquemas de P4P determinantes de su efectividad se refieren a quién debe recibir los incentivos, cuánto debe pagarse, qué debe retribuirse, la necesidad de incorporar ajustes de riesgos (sobre todo en los indicadores de resultados intermedios) y de tener en cuenta el clima organizativo, y la combinación óptima de incentivos financieros y no financieros. Las limitaciones más importantes que cabe considerar son: la orientación exclusiva hacia la reducción de la infrautilización, la afectación de la equidad, el efecto «lupa», la validez de los indicadores, la confusión entre recomendaciones de guías de práctica e indicadores de calidad, la ingeniería documental, el paternalismo con los pacientes, el posible impacto negativo sobre el profesionalismo y la motivación interna de los médicos, y el abordaje de la calidad como un problema de decisiones imperfectas, antes que como un sistema imperfecto.
Palabras clave:
Incentivos
Calidad asistencial
Indicadores de calidad
Abstract
The concept of pay-for-performance (P4P) encompasses different strategies that aim to stimulate health care quality improvement by remunerating healthcare providers according to their performance in specific measures of efficiency or quality. Although the effectiveness of P4P in improving quality of care is largely unknown, these systems are being widely adopted in the United Kingdom, the United States and other countries, including Spain. The elements of P4P design that are most decisive for the effectiveness of these schemes are as follows: 1) who should receive the incentives, how they should be paid, what should be rewarded, the need to incorporate risk adjustments (mainly if surrogate outcomes are used as indicators) and the need to bear organizational climate and the optimal combination of financial and non-financial incentives in mind. The most important limitations to consider are the following: 1) the exclusive focus on reducing subutilization; 2) the effect on equity; 3) the “magnifying glass” effect; 4) the validity of indicators; 5) the confusion between the recommendations of clinical guidelines and quality indicators; 6) “document engineering”; 7) paternalism; 8) the negative impact on professionalism and clinicians’ internal motivation, and 9) the assumption that quality problems result from imperfect individual decisions rather than from an imperfect system.
Key words:
Incentive
Quality of health care
Quality indicators
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