Pay for Quality

KCE Reports 118 Pay for Quality 91
In general we see that all citizens benefit from the improvements in quality of care and
the extent to which they benefit determine whether the existing gap narrows (when the
least off have a larger growth than the best off) or increases (if the least off have a
smaller growth than the best off). However, for some indicators a new gap arises there
where there was no gap pre-contract. For example a significant difference between the
most and least deprived patients emerged after the contract for the recording of blood
pressure, the recording of smoking status and giving smoking advice. Also pre-contract
diabetic women were as likely as men to have their HbA1c, blood pressure, serum
creatinine and cholesterol recorded where post-contract inequities in these indicators
appeared.
For some indicators, the increase in quality of care for the initially deprived groups was
even larger than for the other patients, resulting in an inversion of the gap or a ‘positive
discrimination’: for the measurement of BMI, the measurement of cholesterol and the
control of BP a positive discrimination of South Asian patients with CHD compared to
white British patients with CHD was described. 157 . Also for one indicator in diabetes
care (serum creatinine recorded) the inequity inversed towards a pro-elderly
distribution of the indicator 128 .
In 2000, Victoria et al formulated the inverse equity hypothesis. This hypothesis
proposes that affluent groups in society preferentially benefit from new interventions,
leading to an initial increase in inequalities. Deprived groups only begin to benefit once
affluent groups have extracted maximum benefit. Health inequalities ultimately diminish
because deprived groups start with a lower baseline level of health and health care
uptake and have higher potential gains 148 , 235 . The above results do not unanimously
confirm the first part of the hypothesis (i.e. just after the introduction of a new
intervention the more affluent areas or groups in society benefit most).
With regard to the persistency of these changes over time only two studies were found
84 , 142
. In the first year after the introduction a clear socioeconomic gradient was
recorded, with progressively lower achievement and greater variation in achievement,
with increasing area deprivation. However this gradient was not steep.
Both Doran et al. (2008) and Ashworth et al (2007) showed that after 3 years this
existing (but small) gradient between deprived areas had almost disappeared.
84 , 142
Moreover, using regression models including area, practice, patient and GP
characteristics, Doran was able to prove that the increase in achievement over time was
not significantly associated with area deprivation but was very strongly associated with
previous practice performance: “the lower the achievement in the previous year, the
greater the increase in achievement.” 84
This is a very important finding because it might indicate that the QOF indeed is a truly
equitable public-health intervention since the improvements in quality achievement by
practices are inversely related to previous performance and not to the level of
deprivation of the area where the practice is located. However, alternative explanations
for the described phenomenon could also exist: it is possible that the increase in quality
already started before the introduction of the QOF (there are some indications for this)
and that the better off groups already nearly reached their full growing potential by the
time the QOF was introduced. 84 This might explain the reduction of some of the precontract
health care gaps as described in the previous paragraph 84 .
With regard to exception reporting there is some concern that this might be used as
an excuse for substandard care of patients or to exclude patients for whom the targets
had been missed, mostly socially deprived patients or patients with a different ethnic
background, rather than because of a genuine clinical reason (also known as ‘gaming’).
The most recent and most comprehensive study that addresses this topic is the study of
Doran et al (2008); they report that the characteristics of the patients (e.g. gender,
socioeconomic position) explain only 2.7% of the variance in exception reporting. This
does not confirm earlier studies with more limited study designs reporting that
practices in financially deprived areas are more likely to exclude patients (McLean 2006).
Doran et al (2008) conclude that “Exception reporting brings substantial benefits to
pay-for-performance programmes, providing that the process has been used
appropriately.