Why pay for health insurance should be performance-based

What you need to know:

Essentially, Pay - for - performance (P4P) ties health insurance reimbursements to metric – driven outcomes, proven best practices and patient satisfaction measures.
The practical application of P4P is that health facilities which score highly in healthcare quality indicators are paid more as compared with those which score poorly.
The performance comparison can then either be structured as comparing a particular hospital to its performance in a preceding period or as compared to its peers in the same geographic location or at a similar level of care.

The current buzz topic in healthcare service delivery in Kenya is the Health Amendment Act of 2021.

Among its key facets is the restructuring of the National Hospital Insurance Fund (NHIF) towards bolstering the push for Universal Health Coverage, a critical end-point of which is high-quality healthcare service delivery.

The World Health Organisation describes service delivery as one of the six key building blocks of a healthcare system. The others are leadership and governance, healthcare workforce, financing, access to essential medicines and health information systems.

Prof Joep Lange was a Dutch clinical researcher specialising in HIV therapy and a revered advocate for global equity to high-quality healthcare services. Unfortunately, and tragically so, he passed on in the ill - fated Malaysian Flight 17 which was shot down in Ukraine in 2014. He was enroute to Melbourne to attend the 20th International AIDS Conference.

Prof Lange once opined the now famous ‘food – for - thought’ that, “If we can get cold Coca-Cola and beer to every remote corner of Africa, it should not be impossible to do the same with drugs (and high-quality healthcare)”.

Pay - for - performance (P4P) resonates very well with Prof Lange’s vision. Essentially, P4P ties health insurance reimbursements to metric – driven outcomes, proven best practices and patient satisfaction measures. The practical application of P4P is that health facilities which score highly in healthcare quality indicators are paid more as compared with those which score poorly. This is meant to incentivise the push for high quality healthcare.

It nudges healthcare services providers towards value - based care because it aligns reimbursement payment with quality. Two P4P models exist. The first is that hospitals are rewarded according to how well they perform across process, efficiency and quality measures. The second is that hospitals are penalised for sub-optimal performance against defined indicators. Either can be deployed or a combination of both.

The immediate quagmire that follows is the question of which objective and comparable performance indicators to use in Kenya. The opportunity herein is that we already have quality measurement schema. These include the Kenya Quality Model for Health (KQMH) by Ministry of Health, SafeCare standards by PharmAccess, Joint Commission International (JCI) standards and Council for Health Services Accreditation (COHSASA) standards; all applicable to different healthcare set-ups.

The beauty of all these standards is that they all center on measurable aspects of patient safety, clinical care, efficiency, cost – reduction and patients’ experience. The performance comparison can then either be structured as comparing a particular hospital to its performance in a preceding period or as compared to its peers in the same geographic location or at a similar level of care.

It is worth noting that the development of P4P models requires a very consultative and iterative process; developing, implementation, evaluation, adjustment and re-deploying, so as to generate sufficient buy-in from healthcare services providers, purchasers (insurance schemes) as well as patients. It is also critical that the criteria for comparing performance be publicly reported so as to ensure accountability, fairness and public trust.