Health Care Around the World P4P Quality

Pay-for-performance programs in the United Kingdom

Pay-for-performance is a hot topic in the health policy world. However, one of the largest pay-for-performance programs has already been implemented in the UK’s National Health Service. A paper by Doran et al. (2006) reviews the overall implementation of the NHS’s P4P program as well as how some physicians used exceptions to greatly increase their scores and bonuses.  Some excerpts from the paper are below:

In 2004, the National Health Service committed £1.8 billion ($3.2 billion) in additional funding over a period of three years for a new pay-for-performance program for family practitioners (the sole type of primary care physician in the United Kingdom). This program was intended to increase family practitioners’ income by up to 25 percent, depending on their performance with respect to 146 quality indicators relating to clinical care for 10 chronic diseases, organization of care, and patient experience.9 For the clinical indicators, practices claim points that generate payments according to the proportion of patients for whom they achieve each target…For example, for asthma indicator number 6, practices gain points for clinically reviewing at least 25 percent of patients with asthma in the previous 15 months. The maximum of 20 points is gained if at least 70 percent of patients with asthma are reviewed.

Evidence-based quality indicators should not be applied unthinkingly, since patients have coexisting conditions that affect their optimal care. It is inappropriate, for example, to strive to control the cholesterol level of someone terminally ill with cancer. Consequently, the new U.K. pay-for-performance contract allows family practitioners to exclude patients from eligibility for specific indicators in the performance calculations….However, exception reporting also provides an opportunity for family practitioners to increase their income by inappropriately excluding patients for whom they have missed the targets (a practice known as gaming).

To evaluate P4P in the UK, the authors analyzed family practice data extracted from clinical computing systems in England in the first year of the pay-for-performance program (April 2004 through March 2005).

Exception reporting by practices was not extensive (median rate, 6 percent), but it was the strongest predictor of achievement: a 1 percent increase in the rate of exception reporting was associated with a 0.31 percent increase in reported achievement…A small number of practices appear to have achieved high scores by excluding large numbers of patients by exception reporting


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