MedicalResearch.com Interview with:
Prof. Bruce Guthrie PhD
Head of Population Health Sciences Division
Professor of Primary Care Medicine and Honorary Consultant NHS Fife
MedicalResearch.com: What is the background for this study? What are the main findings?
Response: The UK Quality and Outcomes Framework (QOF)) is a primary care pay for performance programme (P4P) implemented in 2004. QOF was and still is the largest healthcare P4P programme in the world, initially having ~150 indicators and accounting for ~20% of practice income. QOF has been reduced in scale and scope over time, with 40 indicators retired in 2014. It was abolished in Scotland in 2016 and is due to be further reformed in England. There is some evidence that P4P (and QOF itself) is associated with modest improvements in quality when introduced, but little evidence about what happens when financial incentives are withdrawn.
Our study examined what happened when incentives were withdrawn in 2014 for 12 indicators where there is good before and after data. There were immediate reductions in documented quality of care, which were similar in size to improvements observed when incentives were introduced. These reductions were small to modest (~10%) for indicators relating to care that is already systematically delivered (eg routine diabetes, hypertension and cardiovascular disease) and large for indicators which has historically been less systematically delivered (eg lifestyle advice).
MedicalResearch.com: What should readers take away from your report?
Response: Pay for performance programme is no magic bullet for improving quality. Financial incentives will inevitably be withdrawn because the resource to pay for them will be needed to be deployed elsewhere, so the lack of sustained effect on quality after withdrawal is disappointing. P4P or financial incentives do appear to be effective for getting providers’ attention, but sustained improvement in quality that persists after incentives are removed likely requires combining financial incentives with other improvement methods (eg education, training, informatics, support to reorganise care). Payers thinking of using P4P should carefully consider how incentives are best integrated with other improvement methods, and should monitor quality of care after incentives are removed.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: The data available in this analysis only relate to publicly reported quality data. We therefore cannot easily distinguish between changes in the documentation of quality and changes in the actual quality of care delivered. Future research should examine how actual quality of care changed. For example, there were large reductions in documentation of giving women using medically prescribed contraception advice on the value of long acting reversible contraception (LARC). We know that when incentives were introduced, there were increases in the prescription of LARC. When incentives were withdrawn, then the documentation of LARC advice dropped sharply. Knowing whether rates of prescription of LARC also reduce or whether unwanted pregnancies rates increase would be very informative about the clinical effects. More broadly, payers running large P4P programmes could effectively answer many questions about P4P’s impact by randomising practices or physicians to receive incentives or not at the start of programmes, or randomising withdrawal of incentives at the end of programmes. Given the resource being devoted to P4P, such evidence would be invaluable in understanding if it is value for money.
MedicalResearch.com: Is there anything else you would like to add?
Response: From 2009-2015, I was a member of the UK National Institute of Health and Care Excellence QOF Indicators Advisory Group which advised on indicators to be included, but my responses here are in an entirely personal capacity.
Mark Minchin, M.B.A., Martin Roland, D.M., Judith Richardson, M.P.H., Shaun Rowark, M.Sc., and Bruce Guthrie, Ph.D.
N Engl J Med 2018; 379:948-957
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