1. Pay for Performance, Public Reporting, and Disparities: What Do We Know? The Experience of UK Primary Care Tim Doran, University of Manchester Fullwood C, Gravelle H, Kontopantelis E, Reeves D, Roland M

2. Financial incentives in UK primary care Quality and Outcomes Framework introduced in 2004 £1.8 billion ($3.6b) over first 3 years Family practitioner income increased by ~25%, dependent on performance 146 quality indicators Clinical care for 10 chronic diseases Organisation of care Patient experience Indicators reviewed every 2 years

3. Quality indicators Each indicator worth between 1 and 56 points 1,050 points in total Each point earns £76/125 ($150/250) Maximum of $160,000 per practice ($50,000 per physician)

4. Example: CHD 6 The percentage of patients with coronary heart disease whose blood pressure is 150/90 mmHg or less Point score: from 1 point (25%) to 19 points (70%) Income: From $0 to $2,900

5. Protecting patients Quality targets are not always appropriate Contract allows practices to ‘exception report’ inappropriate patients, e.g. patients who: Repeatedly fail to attend Have terminal illness or are extremely frail Can not tolerate medication Do not agree to investigation or treatment

6. BP not controlled (50) coronary heart disease register (100 patients) BP controlled (50) Achievement = 50/100 = 50% ($1,450)

7. BP not controlled (40) BP controlled (50) Achievement = 50/90 = 56% ($1,620) (10) exception reported eligible for target (90 patients)

8. BP not controlled (20) BP controlled (50) Achievement = 50/70 = 71% ($2,900) (10) exception reported ‘eligible’ for target (70 patients) (20) inappropriately exception reported

9. Quality Management and Analysis System

10. Public reporting Results for all practices freely available on NHS Information Centre’s website http://www.qof.ic.nhs.uk/ Local Primary Care Trusts inspect practices Provide advice on improvement Can withhold payments to practices with suspicious results

13. Pay for performance and inequalities

14. Inequalities in health care provision Aim of incentives Improve quality of health care overall Eliminate unacceptable variations in care Potential effect Practices serving deprived populations might perform less well & receive less remuneration Resources diverted away from communities with the greatest need

15. Achievement of targets in 2004-05

16. Achievement of targets in 2005-06

17. Achievement of targets in 2006-07

18. Exclusion by exception reporting

19. Exception reporting rates

20. Gaming of exception reporting Maybe… Higher rates for more difficult activities Higher rates for practices with levels of achievement below maximum thresholds in previous year Maybe not… Rates generally low No association with remuneration on offer

21. Early experiences of P4P in the UK

22. Achievement of targets Achievement levels were generally high (85.1%, 89.3% & 90.8% in Years 1, 2 & 3) Gap in average achievement between practices serving most and least deprived populations diminished 4.0% in Year 1 1.5% in Year 2 0.8% in Year 3 Variation in achievement diminished Practices in deprived areas excluded marginally more patients Extent of gaming yet to be determined

23. Negative effect on health inequalities Incentivised activities mainly concerned with secondary prevention Impact on unincentivised activities, particularly in practices struggling to hit the targets, may be negative Over $2b each year distributed to family practitioners, but then where...?

24. Positive effect on health inequalities Over 60% of the life expectancy gap between most deprived 20% of areas in England and rest of the country is attributable conditions incentivised in the scheme Reported inequalities for incentivised activities have diminished to very small levels over the first three years of the scheme Improvement in achievement associated with performance in Year 1, not area deprivation

25. Further information: tim.doran@man.ac.uk

26. Further reading Ashworth M, Seed P, Armstrong D, Durbaba S, Jones R. The relationship between social deprivation and the quality of primary care: a national survey using indicators from the UK Quality and Outcomes Framework. British Journal of General Practice 2007: 57: 441-448. Campbell S, Reeves D, Kontopantelis E, Sibbald B, Roland M. Quality of primary care in England with the introduction of pay for performance. New England Journal of Medicine 2007; 351: 181-190. Doran T, Fullwood C, Gravelle H, Reeves D, Kontopantelis E, Hiroeh U, Roland M. Pay for performance programs in family practices in the United Kingdom. New England Journal of Medicine 2006; 355: 375-384. Doran T. Lessons from early experience with pay for performance. Disease Management and Health Outcomes 2008; 16(2): 69-77. Gray J, Millett C, Saxena S, Netuveli G, Khunti K, Majeed A. Ethnicity and quality of diabetes care in a health system with universal coverage: population-based cross sectional survey in primary care. J Gen Intern Med. 2007; 22(9): 1317-1320. Gravelle H, Sutton M, Ma A. Doctor behaviour under a pay for performance contract: further evidence from the quality and outcomes framework. CHE Research Paper 32. York: Centre for Health Economics, 2008. Guthrie B, McLean G, Sutton M. Workload and reward in the Quality and Outcomes Framework of the 2004 general practice contract. British Journal of General Practice. 2006; 56: 836-841. The Information Centre. Quality and Outcomes Framework Exception Report. Available from: http://www.ic.nhs.uk/statistics-and-data-collections/audits-and-performance/qof/quality-and-outcomes-framework- exception-report http://www.ic.nhs.uk/statistics-and-data-collections/audits-and-performance/qof/quality-and-outcomes-framework- exception-report The Information Centre. Online GP Practice Results Database. Available from: http://www.qof.ic.nhs.uk/http://www.qof.ic.nhs.uk/ McDonald R, Harrison S, Checkland K, Campbell S, Roland M. Impact of financial incentives on clinical autonomy and internal motivation in primary care: ethnographic study. British Medical Journal 2007; 334: 1357-1362. Roland M. Linking physicians' pay to the quality of care - a major experiment in the United Kingdom. New England Journal of Medicine. 2004; 351: 1448-1454.