British pay-for-performance program surpasses first-year predictions

Report’s findings question whether bar is set too low or if practitioners are exploiting the system.

Issue: Issue 5 2006

The United Kingdom’s pay-for-performance program is yielding higher-than-expected results, leading some to question whether the incentives are too easy to achieve and if family practitioners are dealing in exception reporting.

David L. Hamblen, PhD, FRCS [photo]
David L. Hamblen

The new U.K. pay-for-performance (P4P) contract allows family practitioners to exclude patients with coexisting conditions that may affect care, they added.

A July report in the New England Journal of Medicine found that 8,105 family practices in England reported an 83.4% (range, 78.2% to 87%) median achievement from April 2004 to March 2005.

The U.K. National Health Service (NHS) awarded £76 ($133) for each point earned, ultimately awarding an average of £76,200 ($133,200) to each practice, according to the report.

Are targets set too low?

In an editorial accompanying the report, Arnold M. Epstein, MD, of the Harvard School of Public Health and Harvard Medical School in Boston, said the NHS anticipated that family practitioners would only achieve 75% of the possible points.

“The high level of performance … suggests that the targets were set too low, or that British physicians improved their practices or their documentation of care to meet the new standards, or gamed the system by excluding patients whose care did not meet the performance criteria,” Epstein wrote.

Others have expressed concerns that the NHS is providing these extra incentives to family practitioners for services they were already performing.

“The general practitioners in [England] have been delivering this agenda anyway,” said Orthopaedics Today Consulting Editor David L. Hamblen, PhD, FRCS, of Glasgow. “By giving them more money for delivering all these targets on a formal basis, [the NHS is] really paying more money for the same work in the majority of cases.”

Exception reporting

“We’ve had similar exclusion problems with the independent-sector treatment centers where … people with bad health problems, comorbidity, drug abuse … are not included.”
— David L. Hamblen, PhD, FRCS

The researchers, led by Tim Doran, MPH, of the University of Manchester, found that patient and practice sociodemographic characteristics had a moderate but significant effect on performance, while exception reporting was the strongest predictor of achievement.

The researchers found only a 6% incidence of exception reporting, but they also found that a 1% increase in the exception-reporting rate led to a 0.31% increase in reported achievement. One percent of practices had a high exception-reporting rate of 15%, the researchers said.

“More research is needed to determine whether these practices are excluding patients for sound clinical reasons or in order to increase income,” the researchers wrote in the report.

“We’ve had similar exclusion problems with the independent-sector treatment centers, where they can ‘cherry-pick’ the easy cases, and people with bad health problems, comorbidity, drug abuse … are not included but are left to be treated by the NHS general hospitals,” said Hamblen.

P4P programs must be also ensure good care for patients with complex trauma, cancer and other long-term care problems, “which again aren’t [patients] who earn you money, but they still need good care over a prolonged period,” Hamblen said.

Information technology

Hamblen said a strong information technology (IT) backing is necessary in controlling gaming and other issues in a P4P program.

“Our information technology is still fairly primitive,” Hamblen said. “Individual practices and groups of physicians have quite good IT, but in [England] it certainly isn’t possible yet to link between general practice and hospital environments.”

To address this need, the NHS is overseeing a universal, multi-billion pound IT system project planned for completion within the next two years to three years, Hamblen said.

This year, the NHS revised the P4P scheme. According to the report, the organization raised all minimum and some maximum payment thresholds, dropped or modified 30 indicators and introduced 18 new indicators.

For more information:
Doran T, Fullwood C, Gravelle H, et al. Pay-for-performance programs in family practices in the United Kingdom. N Engl J Med. 2006;355:375-384.
Epstein AM. Paying for performance in the United States and abroad. N Engl J Med. 2006;355:406-408.