Pay for Quality

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42 Pay for Quality KCE Reports 118 125 , 132 , 173 , 180 , 181 , 182 , 184 , 188 , 191 • Age selection criterion: children as target group , 210 , 214 , 217 177 162, 170 , , the elderly as target group , patients older than 50 years 183 , 195 , 202 , inclusion of adult patients only (sometimes depending on measure selection) 124, 127, 128, 144, 154-156, 157, Morrow, 1995 #385, 159, 191, 193, 196, 201, 204, 219, 220 , 36 to 75 years of age 216 . • A ‘regular patient’ criterion: patient seen in practice during six months 184 , 188 , more than one ‘well check’ performed 188 , minimal one year as a patient 188 , minimal three times an office visit 180 , 188 , minimal one visit during the last year 181 , 182 , 188 178 , minimal one office visit during the study period , having an office visit during the three months prior to study period 201 , no mention of patient moving or leaving the practice 181 , 182 , patients with a regular personal physician 204 , regular attendance 214 , receiving care for a total of at least six months 179 , continuously enrolled for at least 18 months 219 , used at least one service during 18 months 219 , patients who have been in the practice’s care for at least one year 69 , seeing no more than two physicians or two physicians equally often 144 . One study focuses explicitly on patients not in regular contact with their provider as a criterion for inclusion: patients with no visits for more than four months 179 . • A language criterion: patient speaks English or Spanish 219 , an informed consent ability criterion: patient could give informed consent 219 , informed consent provided 163 , a physical or functional status criterion: functional limitations or increased need for healthcare services or dependence on medications or home medical equipment 173 , a socio-economical status criterion: low income members of minority groups 144 , an ethnicity criterion: patients with an African American ethnicity 176 , a home setting criterion: non nursing home patients 177 , lived in the community 219 , patients in private households 162 and exclusion of loss due to death or transfer out 195 . • A number of UK P4Q studies based on the QOF, exclude exception reported patients from further analysis 127, 128, 134, 141 . Many studies do not specify how exception reporting has been dealt with. Some studies do an additional control or subgroup analysis for as exception reported patients or interventions 84, 127, 128, 130, 132, 133, 135, 147, 148, 160, 163, 165, 167, 171 . Key points on patient characteristics • Medical conditions targeted by P4Q include mainly preventive care (e.g. immunization, screening) and chronic care (e.g. diabetes care, asthma care). The lower number of P4Q initiatives in acute care focus on conditions as myocardial infarction and pneumonia. Interest in P4Q is growing in many medical specialties, including surgery, but without evaluation results at present. Some studies are not medical condition or patient group specific, but focus on a wider use of disease management or care management processes. Inclusion of patients is often based on medical condition specific clinical selection criteria to define a clinically coherent patient group. • Additional patient selection criteria included in a number of studies are: patient age (children, adults, elderly), the regularity and stability of the patient-physician relationship, patient language, socio-economical status, ethnic background and clinical parameters (e.g. functional status, loss due to death or transfer). • Exception reporting of patients in the UK is often treated ambiguously in the included studies, with some including these patients and some excluding them. Often this remains unclear. A few studies report specific subgroup analyses.
KCE Reports 118 Pay for Quality 43 4.2.4 Description of P4Q interventions 4.2.4.1 United Kingdom Primary care: Quality and Outcomes Framework (QOF) British family practitioners derive their income from NHS patients. Almost all of the citizens of the UK are registered with a family practitioner, and family practitioners have registered lists of patients for whom they are responsible. Their work within the NHS is governed by a national contract, known as the General Medical Services contract that is negotiated between professional representatives of the British Medical Association and the central government. This contract is revised at infrequent intervals; since the NHS started in 1948, major contract revisions have been made only in 1966 and 1990 55 . At the core of the general practitioners contract was the Quality and Outcomes Framework (QOF), which links financial incentives to the quality of care that is provided by practices. The contract for providing medical care and all quality payments relate to the practice rather than to the individual physician. Under the 2004 contract, responsibility moves from the individual family practitioner to the practice, which is a group of, typically, one to six physicians. In 2004, the National Health Service committed £1.8 billion ($3.2 billion) in additional funding over a period of three years for a new pay for performance programme for family practitioners. The quality-of-care payments make up approximately 20 percent of the government’s total family practice budget. These figures are gross numbers and therefore include the additional costs (e.g., for the employment of nurses) that physicians may need to incur in order to deliver high standards of care. The percentage increase in available resources for individual physicians thus depends on the extent to which they have already invested in highquality systems in their practices. This programme was intended to increase family practitioners’ income by up to 25 percent, depending on their performance with respect to 146 quality indicators relating to clinical care for 10 chronic diseases, organization of care, and patient experience. 1. Quality is measured against a set of clinical activity indicators relating to aspects of care for several common chronic diseases, with practices rewarded according to the proportion of eligible patients for whom each target is achieved. Family practitioners earn more points if higher proportions of these patients have undergone “process measures” and further points for “intermediate outcomes” (i.e. management of these risk factors within certain limits). Generally, more points are available for the intermediate outcomes than for the process measures, which reflect the increased difficulty of achieving these standards. The number of points that can be earned for each indicator was determined partly by the academic advisory group and partly by a formal scoring process undertaken by groups of family practitioners in England and Scotland. The intention behind this process was to allocate points on the basis of the workload required to provide care to the relevant standard. For the clinical indicators, practices claim points that generate payments according to the proportion of patients for whom they achieve each target. Points are awarded on a sliding scale within the payment range. For example, for asthma indicator number 6, practices gain points for clinically reviewing at least 25 percent of patients with asthma in the previous 15 months. The maximum of 20 points is gained if at least 70 percent of patients with asthma are reviewed. For 2004–2005, payment was limited to £76 ($133) per point, adjusted for the relative prevalence of the disease (payment is multiplied by the square root of the prevalence of the disease among the patients served by the practice and divided by the square root of the mean national prevalence of the disease). A maximum of 1 050 points was available, which was equivalent
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