Health Policy$ense

Physician Pay-for-Performance – Learning From the British

Dr. Martin Roland on the evidence of impact

“How do we close the gap between the care we actually provide and what ought to be provided?” This was the question posed by Dr. Martin Roland to open a recent seminar at Penn. Roland’s research focuses on the implementation of pay-for-performance schemes in the United Kingdom’s National Health System (NHS). He has found that the evidence of impact on quality of care is modest and mixed.

Roland, who is the RAND Professor of Health Services Research and Director of the Cambridge Center for Health Services Research at the University of Cambridge, has studied the United Kingdom’s experience with the Quality Outcomes Framework (QOF). This pay-for-performance scheme, established in 2004, provides financial incentives to general practitioners (GPs) for improvements in clinical care, practice organization and patient experience.

Providing a behind the scenes view of the QOF’s development, Roland explained how the British Medical Association (BMA), representing the physicians, and the British Department of Health (DoH), representing the government and its contracts with individual GPs, negotiated the program for about 15 months. The BMA had demanded that doctors should be paid more, while the DoH asked for something in return for that extra payment. According to Roland, “quality was what the BMA offered to convince the Treasury that doctors weren’t getting something for nothing.”

Did they get the ‘quality’ that was promised? Sort of. In 2014, Roland and colleagues published findings in the British Medical Journal showing that the QOF reduced emergency hospital admission rates by 2.7% in its first year (2004) and 8% by 2010. The study looked only at conditions that were deemed to be “ambulatory care sensitive conditions” meaning those for which improved quality of care by GPs would make a difference. The authors commented that the decrease is “…larger than would be expected from the changes in the process measures that were incentivised, suggesting that the pay-for-performance scheme may have had impacts on quality of care beyond the directly incentivised activities.”

The evidence based on clinical quality indicators, however, is harder to find. In a New England Journal of Medicine policy report, Roland commented that: “Clinical care probably improved after the introduction of the QOF, though the effects were not compelling and were difficult to disentangle from other ongoing quality ­improvement initiatives.” These other initiatives include changes to national guidelines and the introduction of public reporting of quality of care.

In the NEJM report, Roland noted that the QOF has had some unintended consequences, including some evidence that the program has had adverse effects on the quality of care for conditions that were not included in the program. He also discussed the potential for physicians to game the system in order to maximize income by cherry picking healthier or less complex patients, although he notes that these practices have “not been as widespread as administrators feared.”

The unintended consequences were not all negative, though. At the Penn lecture, Roland explained how clinical data, extracted from the electronic records that the QOF required, has been used to create nationwide public reports on quality of care. The program brought electronic health record adoption from 40% to 100%,  and as a result, he said, the United Kingdom has an electronic medical system that is “built for recording quality, rather than billing.”

The QOF also resulted in a significant shift in the role of nurses and other staffing structures for GP practices. In the NEJM report, Roland writes: “First, there was an increase in nursing staff, with the management of major chronic diseases such as diabetes increasingly moved out of regular response­mode consultations into nurse­run, protocol­driven clinics. Second, there was an increase in administrative staff so that family practitioners could have rapid access to data on their performance.”

The evidence regarding the QOF pay-for-performance program’s ultimate impact on quality of care is mixed, according to Roland. “There is evidence that outcomes improved, but I wouldn’t want to oversell it.” He maintains that there is no magic bullet for quality improvement. “Efforts to improve quality of care with single, short-lived things rarely work. Major improvements are possible if you use multiple and sustained quality improvement strategies.”

For more on physician incentives, and how to make performance measures meaningful, see this Q&A with LDI Senior Fellow Amol Navathe.