quality & outcomes framework (qof)
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Quality & Outcomes Framework (QOF)
02 November, 2017 | Author: Guhan S | Healthcare Business Analyst
CitiusTech Thought
Leadership
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Objectives
Note: Indicators, payment system and other details mentioned in this document are applicable for QOF in England, UK only
Objective of the Document
This document about Quality and Outcome Framework (QOF) aims to give overview of:
The practice of QOF in England
The key changes for 2017/18
Domains and underlying indicators
Process of reward payments, its types of payments and calculation methods and
Exception reporting
Key Stakeholders
This document will give broad understanding of QOF for:
Health IT vendors
General Practitioners
CCGs and other healthcare providers
The document also lists down the direct impact on Healthcare IT
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Overview of QOF
Domains of QOF
Process Flow of Reward Payments
Data Extraction & Achievement Scoring
Payment Methods and its Calculations
Criteria of Exception Reporting
Challenges in using QOF Data
Highlights
References
Agenda
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How does QOF evaluate GPs?
GPs are scored against a set of indicators according to their level of achievement
Higher the achievement points, higher will be the reward
For every point, the practice will be rewarded a maximum of £171.20 (England, 2017/18)
Anatomy
The framework consists of three domains as follows,
Clinical Domain - Managing some of the most common chronic diseases e.g. asthma, diabetes
Public Health Domain - Managing major public health concerns e.g. smoking, obesity
Public Health Domain (Additional services) -implementing preventative measures such as regular blood checks
Click here to refer indicators and thresholds of QOF 2017/18
Overview
Quality and Outcome Framework (QOF) is a voluntary annual incentive programme for GPs in England, detailing practice achievement results
The primary objective of QOF is to drive the quality of primary care and reduce variations in the quality of care amongst GPs
It rewards practices for the provision of quality care. The regulations vary according to the regions in the UK
It also helps to standardize improvements in delivery of primary medical services
Overview of QOF
Key changes for 2017/18
Value of a QOF point is £171.20
The national average practice list size as of 1st Jan’17 is 7732
No changes to thresholds and indicators
QOF Facts: 2015-16
In 2015-16, NHS rewarded 7,619 GPs in England
The average achievement score for practices was 532.9 points out of 559
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Domains of QOF
Clinical Domain - Chronic Diseases
Indicators – 65
Areas – 19 Clinical areas
Max Points – 435
Areas include chronic kidney disease, heart failure, hypertension etc.
Public Health Domain Information Capturing
Indicators – 7
Areas – 4 Clinical areas
Max Points – 97
Areas include blood pressure, cardiovascular disease –primary prevention, obesity18+ and smoking 15+
Public Health Domain -Additional Services
Indicators – 5
Areas – 2 Service areas
Max Points – 27
Areas include cervical screening and contraception
QOF
Indicators: Each domain consists of a set of achievement measures which are developed and reviewed by NICE
Each domain is analyzed with a set of indicators and as per the level of achievement, practices score points against indicators under each domains
The 2017/18 QOF is measured achievement against 77 indicators and can score a maximum of 559 points
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Data Submission GPs record data for the indicators in the Calculating Quality Reporting Service (CQRS) manually or extracted by General Practice Extraction Service (GPES)
Other supporting information is submitted by the GP practices to the Primary Care Trusts (PCTs) as needed
Achievement Scoring
Each indicator is allocated an achievement points and most of the indicators have a threshold of target population which needs to be met by practices to avail rewards
No points for lower limit of threshold, max points for upper limit and proportionately allocated between those limits
Reward QOF offers two methods of reward payments – Aspiration Payments and Achievement payments
Rewards varies with payment methods chosen by the practice
Total points achieved or aspired to achieve by a practice is converted into payment amount by CQRS
Process Flow of Reward Payments
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QOF Reward: Data Extraction & Scoring
Manual Submission
Achievement data for indicators - PC002, SMOK003, CS001, CS004 entered manually on CQRS through a web-based application
A few GPs will need to manually enter the full set of data on CQRS, e.g., shared practices
Manual submission is required when more than one practice has been setup on a single instance of a clinical system and the clinical system supplier is unable to produce separate QOF extracts
Automatic Data Extraction
Anonymized data from GP clinical systems will be automatically extracted by GPES and reported to CQRS
Once the year end extraction is available to view on CQRS, GPs will need to validate the data before declaring achievement in CQRS
CQRS calculates payments based on the points & thresholds applicable for corresponding indicators
GP Clinical System Suppliers as per GP Systems of Choice (GPSoC) are:
In April 2014, CQRS replaced Quality Management and Analysis System (QMAS)
Data Extraction Achievement Scoring
EMIS (EMIS Web) Microtest (Evolution)
TPP (SystmOne) INPS (Vision)
All GP practices that are participating in QOF should submit their achievement data on CQRS (Calculating Quality Reporting Service) to calculate payments
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Reward: Payment Methods
QOF
Aspiration Payments
70% method
Achievement Payments
Clinical and public health domainsAspiration Points total
method
Public Health -Additional Services
Aspiration Payments are payments in advance monthly installments for expected achievement under QOF
Achievement Payments are based on the points that a GP achieves under QOF
Due to the availability of disease registers, Clinical and Public health domains have different method of payment calculation compared to Public Health domain – Additional services
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Payment Methods: Aspiration Payments
Calculation of Monthly Aspiration Payments by the 70% Method
Step 1: QOF Return
The Unadjusted Achievement Payment for the previous year is based on a practice’s QOF Return
• QOF Cash total – Final payment achieved for the previous financial year
• CPI (Contractor Population Index) - a mechanism whereby the QOF payment is adjusted according to the relative list size of the practice
Generally, above calculation is not possible in the first month of financial year,
• QOF Uprating Index – Ratio of QOF point value for current year to that of previous year
• Provisional Achievement Payment – a provisional value set by NHS England for the unadjusted achievement payment based on GP’s return submitted
QOF return = Provisional Achievement Payment * QOF Uprating Index
QOF return = QOF Cash total * CPI
QOF ReturnFinal Aspiration
Payment
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Payment Methods: Aspiration Payments
Calculation of Monthly Aspiration Payments by the 70% Method
Step 2: Final Aspiration Payment
The resulting figure is the annual amount of the Aspiration Payment, which will be paid in 12 monthly installments.
These installments will be adjusted as a necessity when the correct amount of the GP’s achievement Payments in respect to the previous financial year is established
Final score obtained * 70% * (Max QOF point current year / Max QOF point previous year)
QOF ReturnFinal Aspiration
Payment
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Payment Methods: Aspiration Payments
Calculation of Monthly Aspiration Payments by the Aspiration Points Total Method
The Aspiration Points Total is agreed between the practice and NHS England, and is the total number of points that the practice is aspiring towards under the QOF during that financial year
Payment is done in 12 monthly installments over the year
Note: This method applies for new practices only.
Aspiration Payment = (Aspiration Points Total /3) * Value for a QOF point * CPI
How to choose Aspiration Payments
If a GP is to enroll in aspiration payments, it has to be agreed between the GP and the Primary Care Trust (PCT)
• At the start of the financial year; or
• At the time of GMS contract, if it takes effect after the start of the financial year
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Calculation of Achievement Payment in the Clinical and Public Health Domains
Step 1: Percentage of Outcome achieved
Calculate the percentage of GP scores (D),
Where,
• A = the number of patients registered with the GP in respect of whom the task has been performed or the outcome achieved
• B = the number produced by subtracting from the total number of patients registered with the GP with relevant medical condition
• C = the number of patients to be excluded from the calculation on the basis of the provisions in the QOF on exception reporting
D = (A X 100) / (B – C)
Payment Methods: Achievement Payment Calculation
Final Aspiration Payment
Percentage of
Outcome
AchievementPoints
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Calculation of Achievement Payment in the Clinical and Public Health Domains
Step 2: Achievement Points
Calculate the number of points which the practice is entitled to in relation to that indicator
Where,
• E = minimum percentage score set for that indicator (lower threshold)
• F = maximum percentage score set for that indicator (upper threshold)
• G = total number of points available in relation to that indicator
Achievement points = [(D – E) / (F – E)] X G
Payment Methods: Achievement Payment Calculation
Final Aspiration Payment
Percentage of
Outcome
AchievementPoints
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Calculation of Achievement Payment in the Clinical and Public Health Domains
Step 3: Final Achievement Payments
Calculate the achievement payment
Adjusted Practice Disease factor (APDF) - a measure of practice prevalence compared with the national average
From this the NHS England subtracts the value of the relevant Monthly Aspiration Payments made over the year to come up with the practices final Achievement Payment.
For indicators under clinical domain, achievement payment is further multiplied by CPI
Achievement Payment = APDF * Achievement points * QOF points value
Payment Methods: Achievement Payment Calculation
Final Aspiration Payment
Percentage of
Outcome
AchievementPoints
Boolean Indicators – Indicators that don’t have achievement threshold and the points available to these indicators are achieved in full if the task is completed
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Calculation of Achievement Payment in the Public Health - Additional Services Domain
Step 1: Population Outcome = Practice's relevant target population/GPs registered list size
Step 2: Target Population Factor = Population Outcome / [Avg no of patients registered with all practices in the relevant target population / Avg of all practices registered list sizes]
Step3: Achievement payment = Target population factor * QOF points value * Achievement points * CPI
Payment Methods: Achievement Payment Calculation
AchievementPayment
Total PopulationFactor
PopulationOutcome
Indicators under public health – additional services do not apply to all of the GP’s registered population and the achievement points will be paid if the service is offered to the relevant target population
Some indicators such as CS002 and CON003 have achievement thresholds, and the method for calculating achievement points is same as that for this type of indicator in the clinical domain and others are Boolean indicators
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Criteria of Exception Reporting
Exception reporting is intended to allow GPs to pursue the quality improvement agenda without being penalized for patient specific clinical circumstances or other circumstances beyond the GP’s control which leads to failure in achieving the QOF points for certain indicators.
Exception reporting criteria
Patients may be excepted if they fall within the strict criteria detailed below:
Patients who have been recorded as refusing to attend review after being invited on at least three occasions during the financial year
Patients for whom it is not appropriate to review the chronic disease parameters due to particular circumstances
Patients newly diagnosed or who have recently registered with the GP having measurements made within three months and delivery of clinical standards within nine months
Patients who are on maximum tolerated doses of medication whose levels remain sub-optimal
Patients for whom prescribing a medication is not clinically appropriate
Where a patient has not tolerated medication
Where a patient does not agree to investigation or treatment and this has been recorded in their patient record following a discussion with the patient
Where the patient has a supervening condition which makes treatment of their condition inappropriate
Where an investigative service or secondary care service is unavailable
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Unrecognized QOF code
QOF prevalence rates QOF prevalence rates doesn’t consider age, gender, or other factors that
influence the prevalence of health conditions
A practice with high older population might have higher prevalence rate for age-related conditions such as cancer or stroke
Some QOF registers are restricted to include only persons over a specific age. E.g. diabetes registers are based on patients aged 17 and over, for these conditions the QOF-reported prevalence will appear lower than would be the case if the age restriction was also applied to the population denominator
Modification of rules engine
Indicator domains in QOF, underlying indicators with points and threshold level, national practice list size and value of a QOF point gets updated yearly
Health IT companies will require a flexible, scalable and configurable solution to process QOF data, manage indicators and boost prevalence scores for GPs
Challenges in using QOF Data
Patients who might have marked with wrong diagnosis code will never account in the QOF register (e.g., asthma, diabetes, etc.) resulting in lost income
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Results for all practices on the England QOF markers can be used for benchmarking against CCG, regional and national averages
Analysis of patient registry: Identify patients who are not added / could be added to QOF registers to boost prevalence scores
Identify areas which is most productive and cost effective in terms of time spent
QOF Data Processing
Highlights
Most general practices have reached the upper payment thresholds for QOF and therefore maximum remuneration
The percentage of eligible patients recorded as having received the care or achieved the outcome set out by QOF indicators was between 80% and 97%
Pay-for-performance schemes to retain, attract and motivate primary healthcare professional
Five-Year Forward view: Most QOF indicators measures activities that are about single dimensions of primary care elements in Five-Year Forward view
Trend Analysis
QOF finds itself under intense scrutiny following the abolition in Scotland
Health Inequality: QOF has been under-utilized as a tool to tackle health inequality in the UK. To remedy this, QOF could encourage practices to carry out location-specific public health interventions. These includes proactive case finding and primary prevention
It is useful for quality assurance, where the emphasis is more on maintaining a certain level of quality and avoiding adverse events but less for quality improvement
Future of QOF in England
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References
http://content.digital.nhs.uk/qof
https://www.bma.org.uk/-/media/files/pdfs/practical%20advice%20at%20work/contracts/independent%20contractors/qof%20guidance/focusonqofpaymentsnov2013.pdf
http://www.nhsemployers.org/~/media/Employers/Documents/Primary%20care%20contracts/QOF/2016-17/2016-17%20QOF%20guidance%20documents.pdf
http://www.content.digital.nhs.uk/catalogue/PUB22266/qof-1516-anx3-dq-faq.pdf
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5330348/
https://chpi.org.uk/blog/future-qof-primary-care-lessons-diabetes-story-2/
http://blogs.lshtm.ac.uk/prucomm/files/2017/02/Review-of-QOF-21st-December-2016.pdf
http://www.isdscotland.org/Health-Topics/General-Practice/Quality-And-Outcomes-Framework/Information-for-users-of-QOF-register-and-prevalence-data.asp
2020
Thank You
Author:
Guhan S
Healthcare Business Analyst
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