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Healthc Policy. 2008 August; 4(1): 10–15.PMCID: PMC2645205 Copyright © 2008 Longwoods Publishing Pay for Performance in Primary Care: Proceed with Caution, Pitfalls Ahead Brian Hutchison, MD, MSc, FCFP, Editor-in-chief Pay for performance in healthcare – the concept that payment should reflect processes and outcomes of care – has generated growing interest, debate and action among policy makers, health system managers and healthcare providers in Canada and internationally. With the introduction of its Quality and Outcomes Framework (QOF) for primary care in 2004, the United Kingdom raised pay for performance to a new level in both scale and scope (Roland 2004; Roland et al. 2006). The QOF is a voluntary program that provides financial incentives for general practices to meet performance criteria in four domains: clinical (80 indicators), organizational (43 indicators), patient experience (four indicators) and additional services (eight indicators) (National Health Service 2007). General practices can earn up to 1,050 points by meeting these criteria, which were chosen and weighted based on the prevalence and illness burden of the target conditions. Each point is worth approximately £120 ($240 CAD) to the average UK general practice (three GPs with 5,500 registered patients) (Roland 2004). GPs are allowed to exclude patients from eligibility for specific indicators on several grounds, including failure of the patient to respond to repeated invitations to attend for a health review and inappropriateness of an indicator because of terminal illness, extreme frailty or a medication allergy, adverse reaction or contraindication (Doran et al. 2006). Practice-level QOF data are published online ( HYPERLINK \"
http://www.ncbi.nlm.nih.gov/pubmed/17974688\"
Majeed et al. 2007). The QOF is the product of negotiations between the National Health Service (NHS) and the British Medical Association, assisted by academic advisers. In the words of one of those advisers, “Professional representatives were willing to negotiate the provision of care that met higher standards in return for increased resources, and the government was willing to commit additional resources if there was evidence of improved performance” (Roland 2004). Conditions favourable to the QOF initiative included a period of sustained economic growth and increasing government revenues (Roland 2004), professional commitment to evidence-based practice (Wilson et al. 2006) and the availability of computerized clinical and administrative databases that could provide routine information on primary care performance ( HYPERLINK \"
Majeed et al. 2007). The QOF was layered on a series of quality initiatives beginning in the 1990s (Campbell et al. 2005, 2007; Galvin 2006) that were associated with substantial improvements in quality of care during the period leading up to QOF implementation (Campbell et al. 2005). The NHS committed £1 billion ($2.3 billion CAD) annually in new money to the QOF initiative, a 20% increase in the general practice budget (Roland 2004). General practices stood to increase their income by up to 30%, or £42,000 ($96,000 CAD) per GP. In 2004–2005, the first year of the QOF, the average general practice achieved 958.7 points (91% of the 1,050 available), and almost half of all practices scored between 1,000 and 1,050 points ( HYPERLINK \"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645205/\"
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Peckham 2007). The scores were considerably higher than anticipated, and QOF incentive payments substantially exceeded the budget allocation (Doran et al. 2006). These results could reflect unchallenging performance targets, more diligent recording of performance, or quality improvements made in response to, in anticipation of or independent of the QOF incentives. On average, practices serving socio-economically deprived populations achieve lower scores than those serving more affluent populations, although the differences are small (Guthrie et al. 2006; Sutton and McLean 2006; Wright et al. 2006; Doran et al. 2006; Ashworth et al. 2007). The QOF has been criticized for perpetuating the inverse care law (Hart 1971) – those with greatest needs get the least care – by failing to reward the extra work required to achieve quality targets in deprived areas (McLean et al. 2006). In the absence of either a concurrent control group or comprehensive pre-QOF time series data for the QOF indicators, it has been difficult to determine the extent to which QOF has rewarded GPs for what they were already doing (new money for old rope), what they would have done anyway, what they would have done on the basis of transparent performance feedback alone and what they did in response to the financial incentives. Campbell and colleagues (2007) assessed the quality of care for asthma, coronary heart disease and type 2 diabetes among a representative sample of UK general practices at three points in time – two before the introduction of pay for performance (1998 and 2003) and one after (2005). For 30 indicators for which financial incentives were provided under QOF and 17 indicators for which financial incen tives were not provided, they compared mean performance scores in 2005 to scores predicted on the basis of the trend between 1998 and 2003. The rate of improvement in quality of care for diabetes and asthma increased significantly between 2003 and 2005 after the introduction of pay for performance, while the rate for coronary heart disease continued at the same rate. For all three conditions, the rate of improvement between 2003 and 2005 did not differ significantly between incentrivized clinical indicators and those for which incentives were not provided. These findings are consistent with the results of a systematic review of the empirical literature on paying for quality in healthcare and comparable interventions in other sectors, which found little evidence to support the effectiveness of paying for quality (Rosenthal and Frank 2006). In semi-structured interviews conducted just before the implementation of QOF, GPs described significant anticipatory changes in the structure and organization of their practices, including increased employment of nurses to provide nurse-led chronic disease management and triage and management of acute minor illnesses (Roland et al. 2006). They also reported recruitment of data entry clerks in response to the administrative demands of QOF, and “healthcare assistants” to undertake health promotion tasks. Most practices were in the process of refining their data collection processes to deal with QOF reporting requirements. Three years after the introduction of QOF, Campbell and colleagues (2008) conducted semi-structured interviews with 21 GPs and 20 nurses in 22 nationally representative English general practices. Although respondents believed that the QOF incentives had improved disease-specific processes of care and data capture, they described unintended effects, including the emergence of potentially competing patient-centred and QOF-oriented agendas during office visits, a decline in relational continuity between doctors and patients and resentment from nurses failing to benefit financially from QOF incentive payments that flowed to the doctors as employers and owners of the practice. Anecdotally, this last issue has also emerged in Ontario's Family Health Teams in relation to performance-based incentives for appropriate provision of influenza vaccinations, Papanicolau smears, mammography, childhood immunization and colorectal cancer screening. Threats to team relationships are particularly worrisome, given evidence that positive team climate is associated with improved chronic disease management, patient satisfaction, continuity of care and access to care (Campbell et al. 2001). Several commentators (and GPs themselves) have raised concerns about the potential effects of QOF and earlier quality-related initiatives on the motivations, roles and behaviour of GPs (Charles-Jones et al. 2003; Marshall and Harrison 2005;Roland et al. 2006; HYPERLINK \"
Mangin and Toop 2007), based in part on theoretical work in psychology as well as empirical evidence suggesting that for complex tasks, extrinsic incentives tend to reduce intrinsic motivation and performance unless they are consonant with personal and professional interests, values and sense of self ( HYPERLINK \"
Deci et al. 1999;Gagné and Deci 2005). In the context of QOF, the chief worry is that GPs will pursue the QOF agenda at the expense of relational continuity, coordination of care and whole-person, patient-centred care. Concern that physicians had developed an unhealthy focus on the personal financial implications of their clinical activities led Kaiser Permanente to move away from extensive use of performance-based financial incentives and to focus on regular, transparent and systematic performance feedback as the principal driver of quality improvement (Levine 2007). Two potential mechanisms by which GPs might be tempted to “game” the QOF have been identified: classifying patients with borderline clinical measures (e.g., blood pressure) or laboratory values (e.g., blood glucose) as having a condition covered by the criteria ( HYPERLINK \"
Mangin and Toop 2007), and inappropriate exclusion of patients for whom GPs have missed (or are likely to miss) the QOF targets (Doran et al. 2006). The former situation (sometimes referred to as “diagnostic creep”) is particularly worrisome because it could lead to inappropriate treatment and other consequences that flow from disease “labelling” (e.g., Macdonald et al. 1984; HYPERLINK \"
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2645205/\"
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Forrow et al. 1989). However, there is no evidence to indicate whether and to what extent this situation has arisen in the QOF or in other pay-for-performance settings. In the first year of QOF, 1% of practices excluded more than 15% of patients (in one case, 86%), raising the possibility of gaming by a small number of practices (Doran et al. 2006). What lessons can be drawn from experience in the United Kingdom and elsewhere to guide the introduction or refinement of pay for performance in primary care? Depending on the context and design features, pay for performance can yield small gains at large cost, particularly when targets are set in the absence of good baseline (or, better yet, time series) data on performance, and when performance levels – rather than performance improvements – are rewarded. In a US study conducted on a large health plan, physician groups with baseline performance at or above the performance threshold improved the least but received the largest share of bonus payments (Rosenthal et al. 2005). Although in theory, pay-for-performance schemes could be budget-neutral if increased payments to high performers were balanced by reduced payments to low performers, this scenario seems implausible in any setting where providers are represented by a recognized bargaining agent, such as a national or provincial/state medical association. Given the above, policy makers should consider phased and carefully monitored introduction of pay-for-performance initiatives, payments that reward both performance levels and improvements over time, and focusing on a limited set of interventions (which might change over time) selected on the basis of baseline performance levels and potential health gains from improved performance. Sophisticated clinical information systems are a prerequisite for mounting pay-for-performance programs (and for quality improvement initiatives in general). Encouragement of inappropriate testing and treatment can be reduced by allowing the exclusion of patients for whom incentivized interventions are impracticable or inappropriate, recognizing that this opens the door to gaming. To minimize the possibility of negative unintended consequences, especially the dilution of providers' internal motivation, primary care providers should be engaged in the design of pay-for-performance initiatives. Methods for avoiding, identifying and countering unwanted effects, such as provider gaming, impaired team relationships and inequities for socially disadvantaged populations and their primary care providers, need to be thought through and put in place prior to the introduction of a pay-for-performance scheme. Research is needed to establish the incremental effects of financial incentives beyond what can be achieved through ongoing performance feedback, quality improvement facilitators supporting practice-based quality improvement teams and participation in learning collaboratives. For policy makers determined to go down the road of pay for performance despite the uncertainties and potential pitfalls, making haste slowly may be the best course of action. Other Sections▼ References 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;57:441–48.[PMC free article] [ HYPERLINK \"
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PubMed] Campbell S.M., Reeves D., Kontopantelis E., Middleton E., Sibbald B., Roland M. Quality of Primary Care in England with the Introduction of Pay for Performance. New England Journal of Medicine. 2007;357:181–90. [ HYPERLINK \"
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