The role of P4P in quality

improvement

Helen Lester

University of Birmingham

October 26th 2011

What I‟m going to cover

• Where we‟ve come from

• Where we are now and why

• Where we‟re going…

Defining quality

Quality of care for individual patients

• Access - can patients access the heath care they need?

• Safe

• Effectiveness - is it effective when they get there?

• clinical or technical effectiveness

• effectiveness of interpersonal care

Additional domains of quality for populations

• Equity

• Efficiency

• Leading to desired health outcomes

Background: Improving quality in the 1990s

Motive:

• Recognition of care variation by the medical profession

• Recognition of care variation by Government

Means:

• Development of methods of measuring quality

• Increasing computerisation of practices and electronic data record

• Quality improvement initiatives:

National Service Frameworks for major chronic diseases

Audit

• Rise of evidence based medicine

Quality of care in the UK improved

between 1998 and 2003

50

55

60

65

70

75

80

85

90

1997 1998 1999 2000 2001 2002 2003 2004

Overall

sco

re (

max 1

00)

Angina

Diabetes

Asthma

Campbell et al. BMJ 2005; 331: 1121-1123

Background: Improving quality in the

2000s

• “We want to be resourced and rewarded for providing

high quality care”

• In 2001, a BMA ballot found that 86% of GPs would consider resigning if a new contract could not be secured by the BMA

• Political will to invest in the NHS underpinned by sustained economic growth

UK expenditure on health care since 1990

USA: P4P

• In a national survey in USA, 52% of HMOs (covering 81%

of enrollees) report using pay for performance (Rosenthal

2006)

• Average of 5 performance measures per scheme

• Rewards for reaching fixed threshold dominate; only 23%

reward improvement

• 5-7% of physician pay

Domains and points from April 2011

Domain No. of Indicators Pts % of

total

Clinical 87 661 66 Organisational 34 165.5 17 Patient Experience 1 33 3 Additional Services 9 44 4 QP 11 96.5 10

TOTAL 142 1000 100%

Achievement for 50 „stable‟ clinical indicators

Median reported

achievement:

2004/5 84.9%

2005/6 89.2%

2006/7 91.0%

2007/8 90.9%

2008/9 90.8%

What might the effects be?

• Increased computerization

• Better organised care - more systematic protocol driven

care

• Greater job satisfaction

• Improved processes of care

• May be some improvements in outcomes?

Intended consequences

Trends in job satisfaction

5.24

4.6

4.62

3.95

4.674.26

5.23

1

2

3

4

5

6

7

1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

Survey year

Mean o

vera

ll s

ati

sfa

cti

on

Estimated GP practice vacancies per 100,000

patients

2005 2006 2007 2008 2009 2010

England 3 month

GP vacancy rate

2.6% 1.2% 0.9% 0.3% 0.3% 0.5%

Improved care: data from QuIP 1998-2007

Campbell et al NEJM 2007; 357: 181-190 and 2009; 361: 368-378

Asthma

Step change in level (p<0.001)

Improvement post 2005 continued at pre-contract rate

(p=0.16)

Has P4P improved outcomes?

• Data on associations between process performance and

outcomes are mixed

• Work in press from Tim Doran based on QOF suggests that

in absolute terms, improvement in process performance

between 2004-8 resulted in improvement in intermediate

outcomes performance of

o 1.3% (BP)

o 2.0% (CVA)

o 2.2% (Diabetes)

o 3.6% (CHD)

Impact of P4P on hospital costs and mortality

• “The headline finding from this research is that there is an

association between achievement of QOF indicators and

some measurable reduction in costs for hospital care and

mortality outcomes. This association is stronger for some

QOF indicators than others and particularly strong for stroke

care.”

• A single point increase in QOF stroke scores across

England was associated with:

o 2,385 fewer deaths a year

o Reduction in secondary care costs of £22.15 million a year

(Health Foundation report: Do quality improvements in primary care reduce

secondary care costs? February 2011)

Unintended consequences

• Transaction costs

• Changes to practice nurse and salaried doctor roles

• Less holistic approach

• Less attention to non incentivised areas of care

• Equitable health intervention

Transaction costs

• Year 1 (04-05) £76 per point

£624,132,687

• Year 2 (05-06) £125 per point

£1,063,583,954

• Year 3 (06-07) £125 per point

£1,268,175,404

Britons would be far healthier if the NHS paid its doctors less but employed

more of them, a shock international report has concluded.

UK health spending is on a par with other prosperous countries - but its

people are less healthy because too much of the money goes towards GPs'

and consultants' pay packets.

At the same time, Britain has fewer doctors per head of population than most

countries in the Western World - and owns far less hi-tech equipment such as

cancer scanners because it cannot afford them.

Overpaid NHS doctors and too few practitioners

'knocks three years off Britons' lives'

Daily Mail 30th November 2010

What do patients think?

• 52 patients on QOF chronic disease registers in 15 practices

across England

• Interviewed at length Jan-March 2011

• Thought the status quo was great and high trust in their GPs

• No one had heard of QOF

• Almost all thought it strange to reward simple tasks

• What has happened to GPs‟ professionalism?

The value of money as a quality

improvement tool

• The majority thought paying for performance was an inappropriate

quality improvement tool:

“ Personally I think it’s wrong. I think they should deliver the quality of

care because it’s the professional thing to do.” (Male, 54, Hypertension)

“They shouldn’t get rewarded for it because it should be part of their

everyday job.” (Female, 59, CKD)

“ ...you would like to think they were doing it because they thought it

was necessary and a part of your care more than possibly, oh, well, if

we do him we get extra pay. I don’t like the idea of that.” (Male, 77,

Asthma)

Payment for simple tasks

• Most were surprised to hear the practice was paid

money for doing ‘simple things’ :

“Why should you be paid extra for something that is so simple that a

nurse could do it? That doesn’t make any sense.” (Male, 77, Asthma)

“I certainly didn't realise that you got an extra payment for taking

somebody's blood pressure, good heavens.” (Female, 65, Diabetes)

• Incentives should be in place for more complex tasks:

“I know some of them do minor surgery in there and I think they should

have rewards for doing the minor surgery because that saves the

hospital a lot of time...” (Female, 59, CKD)

Impact on care received

• No patient had heard of the QOF

• 75% had not noticed changes in their care:

“I don’t think it has changed at all because I’ve been on that

medication and I’ve always had a review, had my blood

pressure checked every six months.” (Female, 59, CKD)

“I haven’t noticed a difference... I don’t get any letters to

say...I’m due for a blood test or anything like that.” (Male, 87,

Epilepsy)

The importance of baselines: Effect of pay for

performance on blood pressure control and monitoring

Serumaga B et al. BMJ 2011;342:bmj.d108

“They (the GPs) forget we’re actually nurses. You’ve not

stopped all day because you have had ill patients. And

then they come in and tell you that you are 1% down on

a target.” (practice nurse)

“All the three nurses, we agree that we’re doing a lot

more of their work for them (the doctors), and not much

in the way of money recognition.” (practice nurse)

McDonald, Lester and Campbell, Soc Sci Med 2009; 68(7);1206-1212

Changes to nurses‟ roles

Changes to salaried doctor roles

“ “They are feathering their own nests essentially and I do

think that it, the other aspect of it is I think they are abusing

the younger generation of doctors.” (salaried GP)

Lester et al. British Journal of General Practice 2009;59:908-915

“The profession has essentially been bribed to

implement a population based disease management

program that often conflicts with the individual patient

centered ethos of general practice…it comes

dangerously close to medicine by numbers and

threatens the basis of general practice.”

Lipman T. Br J Gen Pract 2005; 55: 396.

Less holistic approach?

Unintended consequences in GP behaviour

• 57 family-practice professionals were interviewed in 24

representative practices across England

• Four particular types of unintended consequences were

identified:

o measure fixation

o tunnel vision

o misinterpretation

o potential gaming

Lester, Hannon and Campbell. BMJ Qual Saf doi:10.1136/bmjqs.2010.048371

What happens to non incentivised areas?

• Longitudinal analysis of achievement rates for 42 activities

(23 included in incentive scheme, 19 not included)

• 148 general practices in England (653 500 patients)

• There was no overall effect on the rate of improvement for

non-incentivised indicators in the first year of the scheme,

but by 2006-7 achievement rates were significantly below

those predicted by pre-incentive trends

• Improvements associated with financial incentives seem to

have been achieved at the expense of small detrimental

effects on aspects of care that were not incentivised

Doran et al. BMJ 2011; 342:d3590 doi: 10.1136/bmj.d3590

Exception reporting by area deprivation

quintile

QOF year

Ove

rall m

ea

n e

xce

ptio

n r

ate

05/06 06/07

02

04

06

08

01

00

Quintile 1Quintile 2Quintile 3Quintile 4Quintile 5

Inequality in quality of care

Achievement by area deprivation quintile

QOF year

Ove

rall r

ep

ort

ed

ach

ieve

me

nt

04/05 05/06 06/07

02

04

06

08

01

00

Quintile 1Quintile 2Quintile 3Quintile 4Quintile 5

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

What happens when you retire indicators?

Keeping plates spinning

• Expectation that work in removed areas will continue since

„embedded‟ in primary care

• GPs in the UK consistently say that this will not be the case

• No UK evidence base to help us answer this question

Kaiser Permanente Northern California Data

• Longitudinal analysis

• 35 medical facilities of Kaiser Permanente Northern California, 1997-2007

• 2 523 659 adult members of KP

• Four „shared‟ indicators

yearly assessment of patient level glycaemic control (HbA1c <8%)

screening for diabetic retinopathy

control of hypertension (systolic blood pressure <140 mm Hg)

screening for cervical cancer

Hypertension Control (systolic<140), ages 20

and up

Red dot: incentive off, Green dot: incentive on

Lester et al BMJ 2010;340:c1898

0

20

40

60

80

100

2002 2003 2004 2005 2006 2007

year

% in

con

rol

Diabetes Glycaemic Control (<8%)

ages 18-75

Red dot: incentive off, Green dot: incentive on

0

20

40

60

80

1999 2000 2001 2002 2003 2004 2005 2006 2007

year

% in

con

trol

Diabetic Retinopathy Screening, ages 31 and up

Red dot: incentive off, Green dot: incentive on

60

80

100

1999 2000 2001 2002 2003 2004 2005 2006 2007

year

% s

cree

ned

Cervical Cancer ages 21-64

Red dot: incentive off, Green dot: incentive on

60

80

1999 2000 2001 2002 2003 2004 2005 2006 2007

year

% s

cree

ned

2011 Cochrane reviews

• Flodgren at al An overview of reviews evaluating the effectiveness of

financial incentives in changing healthcare professional behaviours and

patient outcomes DOI: 10.1002/14651858.CD009255

• “Financial incentives may be effective in changing healthcare

professional practice. The evidence has serious methodological

limitations and is also very limited in its completeness and

generalisability”.

• Scott et al. The effect of financial incentives on the quality of health care

provided by primary care physicians DOI:

10.1002/14651858.CD008451.pub2

• “There is insufficient evidence to support or not support the use of

financial incentives to improve the quality of primary health care.

Implementation should proceed with caution and incentive schemes

should be carefully designed and evaluated.”

State of play 2011- Yes P4P has a role

• Improved care in long term conditions

Achievement for most incentivised activities increased over the first 3 years, but little improvement in Year 4

• Reduced variations in quality of care

The poorest performing practices improved the fastest Overall inequalities in quality of care for incentivised activities almost disappeared by Year 3

• Some staff are happier

4,000 additional physicians recruited (15% increase)

43% GPs are now salaried

Income of GP principals increased by up to 25%

But…

• Too great a cost to the public purse

• Changes to the doctor patient relationship

• Loss of focus on other areas of care

If this was 2003...

• Know the baseline achievement

• Consult the public

• Pilot all indicators

• Attach less money to each measure

• Monitor what happens closely

• Set up some decent longitudinal research to inform the next

Cochrane review

Thank you very much for listening!

H.e.lester@bham.ac.uk