Linking 25% of UK FPs pay to quality of care: a major experiment in quality improvement Martin...
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Transcript of Linking 25% of UK FPs pay to quality of care: a major experiment in quality improvement Martin...
Linking 25% of UK FP’s pay to quality of care: a major experiment
in quality improvement
Martin Roland
Director
National Primary Care Research and Development Centre
University of Manchester
UK
100% quality
Baseline quality
GuidelinesAudit / feedback
Opinion leaders
Financial incentives
?All of these things- no magic bullet
Major UK initiatives• National standards• Clinical governance• Annual appraisal• Public release • Patient safety• Collaboratives• Inspection• Contracts
“With one mighty leap, the NHS vaults
over anything being attempted in the
United States, the previous leader in
quality improvement initiatives.”
Shekelle P. British Medical Journal (editorial) 2003; 326: 457-8
1980s• Quality can’t be measured• There’s no such thing as a bad doctor
2002• Care is too variable• Quality can be measured• Care can be improved• It’s expensive to provide high quality care• We want to be resourced and rewarded for
providing high quality care
Changes in doctors’ views 1980-2002
• Health care quality = electoral liability
• Methods of measuring quality
• Cultural shift: Quality needs to be improved + opportunity for increased income
Quality incentive scheme offering up to 25% increased income to FPs
Collaboration between
•Government
•Academics
•Physicians
New FP contract: Quality and Outcomes Framework
25% of income from quality incentives
• Chronic disease management (Ten conditions)
• Practice organisation (Five areas)
• Patient experience
Roland M. Linking physician pay to quality of care. New England Journal of Medicine 2004; 351: 1448-54.
Seventy six clinical indicators covering:
Coronary heart disease and heart failure (15)
Stroke and transient ischemic attack (10)
Hypertension (5)
Diabetes (18)
Epilepsy (4)
Hypothyroidism (2)
Mental health (5)
Asthma (7)
Chronic obstructive pulmonary disease (8)
Cancer (2)
CHD 7. The percentage of patients with coronary heart disease whose notes have a record of total cholesterol in the previous 15 months.
Point score: from 1 point (25%) to 7 points (90%)
CHD 8. The percentage of patients with coronary heart disease whose last measured total cholesterol (measured in the last 15 months) is 290mg/dl or less
Point score: from 1 point (25%) to 16 points (60%)
Exception reporting for clinical indicators
• Patient refused / not attended despite three reminders
• Not appropriate e.g. supervening clinical condition, extreme frailty, adverse reaction to medication, contraindication etc
• Newly diagnosed or recently registered
• Already on maximum tolerated doses of medication
• Investigative service is unavailable
56 organisational indicators:
Records (19)
Information to patients (8)
Education and training (9)
Practice management (10)
Medicines management (10)
Examples of organisational indicators
Records Smoking status is recorded for 75% of patients between 15 and 75
Medicines managementA medication review is recorded in the preceding 15 months for 80% of patients who receive regular prescriptions but do not need to see the physician each time
Four indicators relating to patient experience:
Conducting and acting on the results of patient surveys (3)
Booking consultations intervals of 10 minutes or more (1)
What might the effects be?
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
• Improved health outcomes
• Reduced health inequalities
• More medicalization, less holistic approach
• Worse care for un-incentivized conditions
• Gaming or misrepresentation
• Change in professional motivation
What might the effects be?
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
• Improved health outcomes
• Reduced health inequalities
• More medicalization, less holistic approach
• Worse care for un-incentivized conditions
• Gaming or misrepresentation
• Change in professional motivation
What might the effects be?
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
• Improved health outcomes
• Reduced health inequalities
• More medicalization, less holistic approach
• Worse care for un-incentivized conditions
• Gaming or misrepresentation
• Change in professional motivation
Potential health impact of new incentives
Impact of increasing quality of care from present levels to highest levels specified in contract
No of cardiovascular events prevented per
5 years per 10,000
Cholesterol lowering in CHD 15.5 Blood pressure control in Hypertension 15.4
McElduff P. et al. Will changes in primary care improve health outcomes. Quality and Safety in Health Care 2004; 13: 191-197
What might the effects be?
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
• Improved health outcomes
• Reduced health inequalities
• More medicalization, less holistic approach
• Worse care for un-incentivized conditions
• Gaming or misrepresentation
• Change in professional motivation
50
60
70
80
90
100
1991 1992 1993 1994 1995 1996 1997 1998 1999
Percentage of practices reaching 80% cervical cytology target
Baker et al. J. Epidemiology and Community Health 2003; 57: 417-423
50
60
70
80
90
100
1991 1992 1993 1994 1995 1996 1997 1998 1999
AffluentareasDeprivedareas
Percentage of practices reaching 80% cervical cytology target
Baker et al. J. Epidemiology and Community Health 2003; 57: 417-423
What might the effects be?
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
• Improved health outcomes
• Reduced health inequalities
• More medicalization, less holistic approach
• Worse care for un-incentivized conditions
• Gaming or misrepresentation
• Change in professional motivation
What might the effects be?
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
• Improved health outcomes
• Reduced health inequalities
• More medicalization, less holistic approach
• Worse care for un-incentivized conditions
• Gaming or misrepresentation
• Change in professional motivation
What might the effects be?
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
• Improved health outcomes
• Reduced health inequalities
• More medicalization, less holistic approach
• Worse care for un-incentivized conditions
• Gaming or misrepresentation
• Change in professional motivation
What might the effects be?
• Increased computerization / admin costs
• More nurses, larger teams, more specialization
• Improved health outcomes
• Reduced health inequalities
• More medicalization, less holistic approach
• Worse care for un-incentivized conditions
• Gaming or misrepresentation
• Change in professional motivation
“The inter-personal side is going to go because the ticks in boxes are going to be all that’s important ..... it’ll be the death of generalism and holistic care …”
“The idea of putting the resources where the morbidity is strikes me as a big advance … and I’m only sorry that it has been softened by the bleatings of those who’ve had it too soft for too long”
“My collective noun for GPs is a grasp of GPs”
Early results – Scotland% of maximum available points scored
010
2030
4050
% o
f pra
ctic
es
0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100Total points scored
Salary Do as little as possible for as
few people as possible
Capitation Do as little as possible for as many people as possible
FFS Do as much as possible, whether or not it helps the patient
Quality Carry out a limited range of highly commendable tasks, but nothing else
Paying physicians: economic theory
Changes in management of diabetes 1998-2003
0
10
20
30
40
50
60
Serum cholesterol5mmol/l or less
BP 150/90 or less HbA1c <7.4%
1998 2003