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Advantages, disadvantages and feasibility of Pay-for-Quality programs in Belgium


Quality of care, as currently measured, shows unintended and avoidable variability in health care, and the existence of under use, overuse and misuse of health care, as compared to best practice. One possible part of the solution is to introduce Pay- for-Quality (P4Q) by aligning the payment system with quality of care. However, there is a lack of comprehensive conceptual guidance on P4Q use in health care.

Reviews of empirical results on P4Q effects concluded that effects are mixed and highly context dependent. The level of acceptance and support by stakeholders in Belgium was unknown. Finally, practical feasibility of P4Q implementation in Belgium was unclear.

This study explored the advantages, disadvantages and feasibility of P4Q implementation in Belgium. A consortium of four universities gathered data from literature, international experts and Belgian stakeholders to assess (1) what can be learned from international P4Q models on design, implementation and evaluation; and (2) what conditions are needed to apply international P4Q models in Belgium; i.e., start from scratch, or enlarge the Belgian quality-improvement programs. The focus of this study was restricted to medical care in primary and acute hospital settings.


This study made use of five types of data collection including (1) the development of a conceptual framework, (2) a systematic review of empirical P4Q evaluation studies up to July 2009, (3) a comparative analysis of P4Q programs in the US, the UK, the Netherlands and Australia, (4) interviews with 40 Belgian stakeholders and (5) a feasibility exercise based on the current operation of 14 existing Belgian quality-improvement initiatives.

The conceptual framework integrated existing theories and practical P4Q design, implementation and evaluation guidance. The systematic review, using a three-reviewer approach, involved searching six databases, reference screening, forward citation tracking, and reaching out to over 60 international experts. Country comparison was based on interviewing six country representatives. The interviews with Belgian stakeholders addressed the opinion of government, physician representatives, insurers, hospital administration, patient advocates, etc. A standardized SWOT template, based on the conceptual framework, was used to assess practical feasibility in the context of existing quality-improvement initiatives.


An integrated conceptual framework is available for national and international use. The systematic review, including 128 studies, identified highly variable effects, from absent to highly improving quality of care, which were very patient-group and target specific. Based on the large amount of evidence, and the additional output of the country comparison, a number of mechanism and context recommendations could be formulated to support a positive outcome (see below).

Stakeholders expressed support of P4Q implementation if recommendations are adhered to. The feasibility exercise identified a limited number of bottlenecks, which can be specifically addressed (e.g., data availability and IT support). Existing quality -improvement initiatives are shown to be a valuable starting point to develop P4Q further.


Future P4Q programs should select and define targets based on baseline room for improvement. As well, they should refocus the program in a timely manner when goals are fulfilled, involve stakeholders, and communicate the program intensively and directly. Furthermore, the following are recommended: an implementation of a uniform P4Q design across payers; a focus on both quality improvement and achievement; support of participation by means of a sufficient incentive size; a distribution of incentives, at least at the individual and/or team level; a provision of quality-improvement support; an evaluation of intended and unintended consequences; and, lastly, a taking into account of both provider and patient characteristics.

Next to the lessons learned, which can be used in practice, other countries or stakeholders who are considering P4Q implementation can use the methods and results of this study to set up the first stage of a P4Q exploration. This will serve as a strong foundation to advance to piloting and demonstration.

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Open Access This article is published under license to BioMed Central Ltd. This is an Open Access article is distributed under the terms of the Creative Commons Attribution 2.0 International License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Van Herck, P., Sermeus, W., Annemans, L. et al. Advantages, disadvantages and feasibility of Pay-for-Quality programs in Belgium. BMC Health Serv Res 10 (Suppl 2), A6 (2010).

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