Paying Physicians for Quality
Primary Care Reform in the UK
Tim Doran
National Primary Care Research and Development Centre
University of Manchester
Québec Medical Association, April 2010
Doran
NPCRDC
Paying Physicians for Quality
Primary Care in the UK
Doran
NPCRDC
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Structure of the National Health Service
Department
of Health
10
Strategic
Health
Authorities
152
Primary Care
Trusts
8,500 / 1,600
General
Practices
NPCRDC
Hospitals
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
New Labour TM
Quality of care, 1997 to 2001
Modernisation
Agency
NPCRDC
Paying Physicians for Quality
Primary Care in the NHS
The 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
The Quality and Outcomes
Framework
Doran
NPCRDC
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Framework
Thresholds and payment
Exception reporting
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
NPCRDC
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Framework
Thresholds and payment
Exception reporting
The quality indicators
Clinical indicators
Disease area
Indicators
Points
asthma
7
72
cancer
2
12
chronic obstructive pulmonary disease
8
45
coronary heart
heart disease
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 NHS
The Quality and Outcomes Framework
Effects of the Reforms
Framework
Thresholds and payment
Exception reporting
The quality indicators
Organisational 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 NHS
The Quality and Outcomes Framework
Effects of the Reforms
Framework
Thresholds and payment
Exception reporting
Achievement thresholds
CHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg
20
•
Points:
0 to 19 points
Income:
£0 to £1,444
(C$0 to C$2,240)
18
Minimum
threshold
16
Maximum
threshold
14
Points scored
•
12
10
8
6
4
2
0
0
5
10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100
Percentage achievement
NPCRDC
Paying Physicians for Quality
“…fragmentation and
privatisation of primary
care…”
‘LOSS OF
CORE
VALUES’
“…losing our professional
identity and reputation.”
‘DE-PROFESSIONALIZATION’
“…the fingerprints of the
World Trade Organisation and
the huge financial muscle
of the medical industrial
complex …”
“…deeply corrosive to
the ethical practice of
medicine.”
‘COERCION
OF PATIENTS’
“…threatens the very
survival of the NHS.”
“…hazardous
interactions and
iatrogenic illness…”
“…loss of
critical
thinking.”
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Framework
Thresholds and payment
Exception reporting
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
size
o Maximum 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 2
o No restriction on how remuneration is distributed
NPCRDC
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Framework
Thresholds and payment
Exception reporting
Exception reporting
CHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg
coronary heart disease
register – 100 patients
50
blood
pressure
controlled
50
Achievement = 50/100 = 50% = 10.6 points = £800 (C$1,240)
NPCRDC
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Framework
Thresholds and payment
Exception reporting
Exception reporting
CHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg
coronary heart disease
register – 100 patients
exception
reported
10
40
blood
pressure
controlled
50
Achievement = 50/90 = 56% = 13.1 points = £995 (C$1,540)
NPCRDC
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Framework
Thresholds and payment
Exception reporting
Exception reporting
CHD6: Percentage of coronary heart disease patients with BP ≤ 150/90 mmHg
coronary heart disease
register – 100 patients
exception
reported
10
20
blood
pressure
controlled
inappropriately
exception
reported
50
20
Achievement = 50/70 = 71% = 19 points = £1,444 (C$2,240)
NPCRDC
Paying Physicians for Quality
Results of the Framework
Doran
NPCRDC
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Results for Years 1-4
Points scored and remuneration
Year
% of total
points
scored
Mean
earnings
per physician
2004-05
91.3%
C$ 35,260
2005-06
96.3%
C$ 61,210
2006-07
95.5%
C$ 57,815
2007-08
96.8%
C$ 58,590
NHS Information Centre (www.qof.ic.nhs.uk)
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Achievement of incentivised indicators
100
90
Achievement rate
80
70
60
Measurement
50
Treatment
Outcome
40
30
20
10
0
2000/1
2001/2
2002/3
2003/4
NPCRDC
2004/5
2005/6
2006/7
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Achievement of incentivised indicators
100
90
Achievement rate
80
70
60
50
40
30
20
10
0
2000/1
2001/2
2002/3
2003/4
NPCRDC
2004/5
2005/6
Paying Physicians for Quality
2006/7
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Uplift in achievement
Incentivized and unicentivized indicators
6
Uplift in achievement
5
4
3
2
Incentivized
Unincentivized
1
0
-1
-2
-3
2004/5
2006/7
NPCRDC
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Inequality in quality of care
60
40
20
Quintile 1
Quintile 2
Quintile 3
Quintile 4
Quintile 5
0
Overall reported
achievement
achievement
Reported
80
100
Achievement by area deprivation quintile
04/05
2004-05
05/06
2005-06
06/07
2006-07
QOF year
Doran et al. Lancet 2008; 372: 728-736.
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Incentivised process
AST7: Asthmatics immunised against influenza in previous season
100%
90%
Achievement rate
80%
70%
60%
50%
40%
30%
20%
10%
0%
1999
2000
2001
2002
NPCRDC
2003
2004
2005
Paying Physicians for Quality
2006
“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
Summary
Doran
NPCRDC
Paying Physicians for Quality
Summary
Summary
Quality of care for incentivized indicators
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
Summary
Summary
Quality of care for partially incentivized and unincentivized indicators
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
Conclusions
Lessons from the UK’s experiment with pay-for-performance
Create the necessary infrastructure
Establish baseline performance
Involve physicians and patient groups from an early stage
Base indicators on important outcomes if possible
Pilot indicators and model allocation formulae
Regularly review all elements of the scheme
Monitor effects on professional behaviour and morale
NPCRDC
Paying Physicians for Quality
Primary Care in the NHS
The Quality and Outcomes Framework
Effects of the Reforms
Effect of increasing payment thresholds
Treatment: treated with beta blocker
Number of practices
Maximum
threshold
Percentage achievement
NPCRDC
Paying Physicians for Quality
Further information: tim.doran@manchester.ac.uk