doran paying physicians for quality primary care reform in the uk tim doran national primary care...
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Doran
Paying Physicians for QualityPrimary Care Reform in the UK
Tim Doran
National Primary Care Research and Development CentreUniversity of Manchester
Québec Medical Association, April 2010
NPCRDC Paying Physicians for Quality
Doran
Primary Care in the UK
NPCRDC Paying Physicians for Quality
Structure of the National Health Service
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
NPCRDC Paying Physicians for Quality
New Labour TM
Quality of care, 1997 to 2001
Modernisation Agency
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
NHS Spending
“... health spending will increase by about 5% annually for five years...”
“You’ve stolen my bloody budget!”
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
Doran
The Quality and Outcomes Framework
NPCRDC Paying Physicians for Quality
The Quality and Outcomes Framework (QOF)The original framework
o Introduced April 2004 for all general practices in the UKo 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
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
FrameworkThresholds and paymentException reporting
The quality indicatorsClinical 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
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
FrameworkThresholds and paymentException reporting
The quality indicatorsOrganisational indicators
Activity Indicators Points
Organisation of care 56 184
record keeping 19 85
patient communication 8 8
education and training 9 29
practice management 10 20
medicines management 10 42
Patient experience 4 100
Additional services 10 36
Access --- 50
Overall quality --- 30
Holistic care --- 100
total 70 500
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
FrameworkThresholds and paymentException reporting
Achievement thresholdsCHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg
0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48 51 54 57 60 63 66 69 72 75 78 81 84 87 90 93 96 990
2
4
6
8
10
12
14
16
18
20
Percentage achievement
Poin
ts s
core
d
Minimum threshold
Maximum threshold
•Points: 0 to 19 points
•Income:£0 to £1,444 (C$0 to C$2,240)
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
FrameworkThresholds and paymentException reporting
“…fragmentation andprivatisation of primary care…”
“…the fingerprints of the World Trade Organisation and the huge financial muscleof the medical industrial complex …”
‘COERCION OF PATIENTS’
“…hazardousinteractions and iatrogenic illness…”
“…threatens the very survival of the NHS.”
“…losing our professional identity and reputation.”
“…deeply corrosive to the ethical practice of medicine.”
“…loss of critical thinking.”
‘DE-PROFESSIONALIZATION’
‘LOSS OF CORE
VALUES’
The Quality and Outcomes Framework (QOF)Remunerating practices
o Each point scored earns an average practice £76 (C$118)o Remuneration adjusted for disease prevalence and list
sizeoMaximum of
• £79,800 (C$124,000) per practice• £25,000 (C$39,000) per physician
o Payment increased to £125 (C$194) per point in Year 2o No restriction on how remuneration is distributed
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
FrameworkThresholds and paymentException reporting
coronary heart disease register – 100 patients
blood pressure
controlled
Achievement = 50/100 = 50% = 10.6 points = £800 (C$1,240)
50
50
Exception reportingCHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
FrameworkThresholds and paymentException reporting
coronary heart disease register – 100 patients
blood pressure
controlled
Achievement = 50/90 = 56% = 13.1 points = £995 (C$1,540)
50
40
Exception reportingCHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg
10
exception reported
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
FrameworkThresholds and paymentException reporting
coronary heart disease register – 100 patients
blood pressure
controlled
Achievement = 50/70 = 71% = 19 points = £1,444 (C$2,240)
50
20
Exception reportingCHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg
10
exception reported
20
inappropriately exception reported
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
FrameworkThresholds and paymentException reporting
Doran
Results of the Framework
NPCRDC Paying Physicians for Quality
NHS Information Centre (www.qof.ic.nhs.uk)
Year % of total points scored
Mean earnings
per physician
2004-05 91.3% C$ 35,260
2005-06 96.3% C$ 61,210
2006-07 95.5% C$ 57,815
2007-08 96.8% C$ 58,590
Results for Years 1-4Points scored and remuneration
Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/70
10
20
30
40
50
60
70
80
90
100
MeasurementTreatmentOutcome
Achievement of incentivised indicatorsAc
hiev
emen
t rat
e
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/70
10
20
30
40
50
60
70
80
90
100
Achievement of incentivised indicatorsAc
hiev
emen
t rat
e
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
-2
-1
0
1
2
3
4
5
Incentivized Unincentivized
Uplift in achievementIncentivized and unicentivized indicators
Upl
ift in
ach
ieve
men
t
2004/5 2006/7
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
Inequality in quality of careAchievement by area deprivation quintile
Doran et al. Lancet 2008; 372: 728-736.
QOF year
Ove
rall
repo
rted
achi
evem
ent
04/05 05/06 06/07
020
4060
8010
0
Quintile 1Quintile 2Quintile 3Quintile 4Quintile 5
2004-05 2005-06 2006-07
Repo
rted
ac
hiev
emen
t
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
Paying Physicians for Quality
1999 2000 2001 2002 2003 2004 2005 20060%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Incentivised processAST7: Asthmatics immunised against influenza in previous season
Achi
evem
ent r
ate
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
“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
NPCRDC Paying Physicians for Quality
o Quality of care• Achievement increased in Years 1-3• Significant improvement over projected rates
(up to 38% in Year 1) • Achievement plateaud from Year 2 onwards
o Inequality of care• Poorest performing practices improved the
most• Inequalities almost disappeared by Year 3
NPCRDC Paying Physicians for Quality
SummaryQuality of care for incentivized indicators
Summary
o Quality of care – unincentivized indicators• Little effect on achievement in Year 1• Borderline underachievement by Year 3
up to 10% below projected rates
o Inequality of care• ???
NPCRDC Paying Physicians for Quality
SummaryQuality of care for partially incentivized and unincentivized indicators
Summary
ConclusionsLessons from the UK’s experiment with pay-for-performance
NPCRDC Paying Physicians for Quality
Create the necessary infrastructure
Regularly review all elements of the scheme
Pilot indicators and model allocation formulae
Base indicators on important outcomes if possible
Involve physicians and patient groups from an early stage
Establish baseline performance
Monitor effects on professional behaviour and morale
Effect of increasing payment thresholdsTreatment: treated with beta blocker
Percentage achievement
Num
ber o
f pra
ctice
s
Maximum threshold
NPCRDC Paying Physicians for Quality
Primary Care in the NHSThe Quality and Outcomes Framework
Effects of the Reforms
Further information: [email protected]