Upload
theodora-wade
View
212
Download
0
Tags:
Embed Size (px)
Citation preview
Pay for Performance, Public Reporting, and Disparities: What Do We Know?
The Experience of UK Primary Care
Tim Doran, University of Manchester
Fullwood C, Gravelle H, Kontopantelis E, Reeves D, Roland M
Financial incentives in UK primary care Quality and Outcomes Framework introduced in
2004 £1.8 billion ($3.6b) over first 3 years Family practitioner income increased by ~25%,
dependent on performance 146 quality indicators
Clinical care for 10 chronic diseases Organisation of care Patient experience
Indicators reviewed every 2 years
Quality indicators Each indicator worth between 1 and 56
points 1,050 points in total Each point earns £76/125 ($150/250) Maximum of $160,000 per practice
($50,000 per physician)
Example: CHD 6 The percentage of patients with coronary
heart disease whose blood pressure is 150/90 mmHg or less
Point score: from 1 point (25%) to 19 points (70%)
Income: From $0 to $2,900
Protecting patients Quality targets are not always appropriate Contract allows practices to ‘exception
report’ inappropriate patients, e.g. patients who: Repeatedly fail to attend Have terminal illness or are extremely frail Can not tolerate medication Do not agree to investigation or treatment
BP not controlled
(50)
coronary heart disease register (100 patients)
BP controlled
(50)
Achievement = 50/100 = 50% ($1,450)
BP not controlled
(40)
BP controlled
(50)
Achievement = 50/90 = 56% ($1,620)
(10)exception reported
eligible for target (90 patients)
BP not controlled
(20)
BP controlled
(50)
Achievement = 50/70 = 71% ($2,900)
(10)exception reported‘eligible’ for target
(70 patients)
(20)
inappropriately exception reported
Quality Management and Analysis System
Public reporting Results for all practices freely available on
NHS Information Centre’s website http://www.qof.ic.nhs.uk/
Local Primary Care Trusts inspect practices Provide advice on improvement Can withhold payments to practices with
suspicious results
Pay for performance and inequalities
Inequalities in health care provision Aim of incentives
Improve quality of health care overall Eliminate unacceptable variations in care
Potential effect Practices serving deprived populations might
perform less well & receive less remuneration Resources diverted away from communities with
the greatest need
QOF year
Ove
rall
rep
ort
ed
ach
ieve
me
nt
04/05 05/06 06/07
02
04
06
08
01
00
Quintile 1Quintile 2Quintile 3Quintile 4Quintile 5
Achievement of targets in 2004-05
QOF year
Ove
rall
rep
ort
ed
ach
ieve
me
nt
04/05 05/06 06/07
02
04
06
08
01
00
Quintile 1Quintile 2Quintile 3Quintile 4Quintile 5
Achievement of targets in 2005-06
QOF year
Ove
rall
rep
ort
ed
ach
ieve
me
nt
04/05 05/06 06/07
02
04
06
08
01
00
Quintile 1Quintile 2Quintile 3Quintile 4Quintile 5
Achievement of targets in 2006-07
Exclusion by exception reporting
QOF year
Ove
rall
me
an
exc
ep
tion
ra
te
05/06 06/07
02
04
06
08
01
00
Quintile 1Quintile 2Quintile 3Quintile 4Quintile 5
Exception reporting rates
Gaming of exception reporting Maybe…
Higher rates for more difficult activities Higher rates for practices with levels of achievement
below maximum thresholds in previous year
Maybe not… Rates generally low No association with remuneration on offer
Early experiences of P4P in the UK
Achievement of targets Achievement levels were generally high (85.1%, 89.3%
& 90.8% in Years 1, 2 & 3) Gap in average achievement between practices serving
most and least deprived populations diminished 4.0% in Year 1 1.5% in Year 2 0.8% in Year 3
Variation in achievement diminished Practices in deprived areas excluded marginally more
patients Extent of gaming yet to be determined
Negative effect on health inequalities Incentivised activities mainly concerned with
secondary prevention Impact on unincentivised activities, particularly in
practices struggling to hit the targets, may be negative
Over $2b each year distributed to family practitioners, but then where...?
Positive effect on health inequalities Over 60% of the life expectancy gap between
most deprived 20% of areas in England and rest of the country is attributable conditions incentivised in the scheme
Reported inequalities for incentivised activities have diminished to very small levels over the first three years of the scheme
Improvement in achievement associated with performance in Year 1, not area deprivation
Further information:[email protected]
Further reading Ashworth M, Seed P, Armstrong D, Durbaba S, Jones R. The relationship between social deprivation and the quality
of primary care: a national survey using indicators from the UK Quality and Outcomes Framework. British Journal of General Practice 2007: 57: 441-448.
Campbell S, Reeves D, Kontopantelis E, Sibbald B, Roland M. Quality of primary care in England with the introduction of pay for performance. New England Journal of Medicine 2007; 351: 181-190.
Doran T, Fullwood C, Gravelle H, Reeves D, Kontopantelis E, Hiroeh U, Roland M. Pay for performance programs in family practices in the United Kingdom. New England Journal of Medicine 2006; 355: 375-384.
Doran T. Lessons from early experience with pay for performance. Disease Management and Health Outcomes 2008; 16(2): 69-77.
Gray J, Millett C, Saxena S, Netuveli G, Khunti K, Majeed A. Ethnicity and quality of diabetes care in a health system with universal coverage: population-based cross sectional survey in primary care. J Gen Intern Med. 2007; 22(9): 1317-1320.
Gravelle H, Sutton M, Ma A. Doctor behaviour under a pay for performance contract: further evidence from the quality and outcomes framework. CHE Research Paper 32. York: Centre for Health Economics, 2008.
Guthrie B, McLean G, Sutton M. Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract. British Journal of General Practice. 2006; 56: 836-841.
The Information Centre. Quality and Outcomes Framework Exception Report. Available from: http://www.ic.nhs.uk/statistics-and-data-collections/audits-and-performance/qof/quality-and-outcomes-framework-exception-report
The Information Centre. Online GP Practice Results Database. Available from: http://www.qof.ic.nhs.uk/ McDonald R, Harrison S, Checkland K, Campbell S, Roland M. Impact of financial incentives on clinical autonomy
and internal motivation in primary care: ethnographic study. British Medical Journal 2007; 334: 1357-1362. Roland M. Linking physicians' pay to the quality of care - a major experiment in the United Kingdom. New England
Journal of Medicine. 2004; 351: 1448-1454.