remuneration of primary care paying for performance in the uk · paying for performance the quality...

Doran

Remuneration of Primary Care

Paying for Performance in the UK

Tim Doran

University of York

NPCRDC Paying Physicians for Quality

NPCRDC

• Capitation do as little as possible for as many people as possible

• Salary do as little as possible for as few people as possible

• Fee-for-service do as much as possible, even it helps nobody…

Paying physicians: a cynics guide

Paying Physicians for Quality

Physician payment mechanisms Paying for quality

Paying for quality The United Kingdom

Summary

The Quality and Outcomes Framework (QOF) The original framework

o Introduced April 2004 for all general practices in the UK

o 146 quality indicators covering:

• secondary prevention for 10 chronic conditions

• organisation of care

• patient experience

• additional services

o Each indicator allocated between 0.5 and 56 points (1,050 in total)

o Achievement scores are publicly reported

• www.qof.ic.nhs.uk


Quality in the NHS The Quality and Outcomes Framework Study results


Summary

http://www.qof.ic.nhs.uk/

The quality indicators Clinical indicators

Disease area Indicators Points

asthma 7 72

cancer 2 12

chronic obstructive pulmonary disease 8 45

coronary heart disease 15 121

diabetes 18 99

epilepsy 4 16

hypertension 5 105

hypothyroidism 2 8

mental health 5 41

stroke 10 31

total 76 550

Disease area Indicators Points

asthma 7 72

cancer 2 12

chronic obstructive pulmonary disease 8 45

coronary heart disease 15 121

diabetes 18 99

epilepsy 4 16

hypertension 5 105

hypothyroidism 2 8

mental health 5 41

stroke 10 31

total 76 550



Summary

NPCRDC


Rewarding performance Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg

0

2

4

6

8

10

12

14

16

18

20

0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100

Po

ints

sco

red

Percentage achievement

Minimum threshold

Maximum threshold

• Points: 0 to 19 points

• Income: $0 to $3,500


• Total points: 1,000

• Maximum income: $187,500 (practice)

$45,000 (physician)



Summary

coronary heart disease register – 100 patients

blood pressure

controlled

Achievement = 50/100 = 50% = 10.6 points = £800 ($1,280)

50

50

Exception reporting CHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg



Summary



blood pressure

controlled

Achievement = 50/90 = 56% = 13.1 points = £995 ($1,590)

50

40


10

exception reported



Summary



blood pressure

controlled

Achievement = 50/70 = 71% = 19 points = £1,444 ($2,310)

50

20


10

exception reported

20

inappropriately exception reported



Summary


Achievement of clinical targets Measurement: record of blood pressure in previous 15 months

Mean:

Year 1 82.3%

Year 2 87.8%

Year 3 89.7%

Year 4 90.0%


Nu

mb

er

of

pra

ctic

es

Maximum threshold


Paying for performance The Quality and Outcomes Framework

US programmes

The UK context The Framework Quality of care under the QOF

Achievement of clinical targets Intermediate outcome: blood pressure ≤150/90 mmHg

Nu

mb

er

of

pra

ctic

es


Maximum threshold


Paying for performance The Quality and Outcomes Framework

US programmes

The UK context The Framework Quality of care under the QOF

50

55

60

65

70

75

80

85

90

95

100

2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7

Incentivized

Unincentivized

Influenza immunisation Incentivized (coronary heart disease) and unincentivized (chronic kidney disease)

Ach

ieve

me

nt

rate




Summary

Inequality in quality of care Achievement by area deprivation quintile – Year 1

Doran et al. Lancet 2008; 372: 728-736.



50

55

60

65

70

75

80

85

90

95

100

1 2 3 4 5

Perc

enta

ge a

chie

vem

ent

(most affluent) (most deprived) Deprivation quintile


Summary

50

55

60

65

70

75

80

85

90

95

100

1 2 3 4 5

Inequality in quality of care Achievement by area deprivation quintile – Year 3

Doran et al. Lancet 2008; 372: 728-736.



(most affluent) (most deprived) Deprivation quintile

Perc

enta

ge a

chie

vem

ent


Summary

Quality of care under the UK P4P scheme

Indentifying indicators to retire Reported achievement and exception reporting in Year 4 (2007-08)

NPCRDC

Retiring indicators Why? How? Consequences?

0

5

10

15

20

25

30

0 20 40 60 80 100

Exce

pti

on

rep

ort

ing

rate

Reported achievement

Quality of care under the UK P4P scheme

Potential retirees 9 indicators meeting criteria

NPCRDC

Retiring indicators Why? How? Consequences?

Domain Indicator Activity

CHD CHD 5 BP measured

Diabetes DM5 HbA1c measured

DM11 BP measured

DM14/22 Creatinine measured

DM16 Cholesterol measured

Mental health MH4 Creatinine measured TSH measured

Smoking SMO1 Smoking status

Stroke STR5 BP measured

Thyroid THY2 TFT measured

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1999 2000 2001 2002 2003 2004 2005 2006

Effect of withdrawing incentives Percentage of asthmatics immunised against influenza

Ach

ieve

me

nt

rate




Summary

“I actually think it's a good idea… it makes things tangible

and quantifies things…

…although I hate it.”

McDonald et al BMJ 2007;334:1357

Doran

Summary


o Incentivized aspects of care • Significant improvement over projected rates in first year of incentives • Little improvement after Year 2 • Greatest improvements in poorest performing practices, located in more deprived areas


Effect of incentives on quality Results from UK Quality and Outcomes Framework

o Unincentivized aspects of care • Little effect on quality in Year 1 • Borderline underachievement by Year 3 • Benefit of incentives may be lost following withdrawal


Summary

Doran T, Roland M. Health Affairs 2010; 29: 1023-1029. Paying Physicians for Quality

Lessons for designers of PFP schemes

o Install the necessary infrastructure (e.g. IT systems)

o Establish baseline performance and identify associated factors

o Involve physicians and patient groups early on

o Base indicators on important outcomes (or on processes with strong evidence of improved outcomes)

o Regularly review the scheme - including impact on unincentivized aspects of care

o Monitor effects on professional behaviour & morale


Summary

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