International Programs

 

P4P is an increasingly international phenomenon. Manion (163) outlines case results of P4P in selected countries, while Wilson (227) makes the case for learning from other countries to improve quality, and Majeed (154) suggests using P4P to compare physicians locally as well as globally. Cupples (284) advises against importing measures.  In comparing and contrasting P4P in the United States and abroad, P4P in the United States is comparatively under-regulated and decentralized, with greater than 160 individual programs, almost exclusively administered by local insurers, lacking either risk adjustment or patient exceptions or both. Other countries that have robust P4P systems include the United Kingdom (see next paragraph), Australia (229, 253, 283), and New Zealand (201). Canada is gradually developing P4P at the provincial level (62, 63), and has additionally developed measures to help reduce queues and increase efficiency (298). The Netherlands aggressively redesigned their system of clinician reimbursement in 2006 to blend risk adjusted, capitated medical homes with bonus fee-for-service payments for complex patients, all in the context of mandatory quality improvement projects to qualify for higher reimbursement (122, 123). Custers (306), from the Netherlands, argues that market trends limit the ability of P4P to impact quality. Rubenstein (298) summarizes a P4P program in Argentina, and argues that P4P must be a part of a greater quality improvement project.

In the United Kingdom (UK), the P4P program is named the Quality and Outcomes Framework (QOF). Authors (59, 184, 211) summarize P4P in the UK and its importance as a tool for quality improvement. Doran (164) offers insights into the QOF based on data from 2004-2007. Specifically, Campbell (162) showed that P4P negatively affected relationships between doctors, nurses, and patients. Campbell (209) also showed modest acceleration of quality improvement in diabetes and asthma after QOF implementation. Doran discusses both the necessity of offering exclusion reporting (186), and showed that only small amounts of physicians have used exclusion reporting many times (194). Satin (242) argues that if the UK and New Zealand are capable of risk adjusting, all programs should find ways to risk adjust.

 

UK NHS: The Quality and Outcomes Framework:

http://www.qof.ic.nhs.uk/

Australia: Practice Incentives Program:

http://www.medicareaustralia.gov.au/provider/incentives/pip/index.jsp

New Zealand:

http://www.moh.govt.nz/dhbfp

 

View Dr. Satin's PowerPoint presentation comparing and contrasting P4P in the US, UK, Australia, and New Zealand, with reference to Canada.

 

International Program Literature

 

Key Article

(59) Mannion, R, Davies H. Payment for performance in health care. British Medical Journal. 2008: 336 306-308.

PMID: 18258966

Summary:

  • Financial reward is a key factor in the success of P4P.
  • Article addresses the good vs. bad of both high and low financial reward.
  • Evaluation of P4P has not been able to keep up with implementation.
  • Preliminary evaluations of the quality and outcomes framework show benefits and adverse consequences.

Significance to Literature:

Summary of P4P in the United Kingdom in February 2008.

 

(62) Landon BE. Is Pay-for-Performance Moving North? P4P Prospects in the Canadian Healthcare System. Healthcare Papers. 2006: 6(4) 24-33.

PMID: 16825854

Summary:

  • Canada has yet to implement a P4P system.
  • Compares P4P potential in United States, United Kingdom, and Canada.
  • Discusses proposal for regional level P4P.

Significance to Literature:

International comparisons of P4P potential, focusing on Canada.

 

(63) Pink GH et al. The Authors Respond. Healthcare Papers. 2006: 6(4) 72-74.

Summary:

  • Authors point out that there are several P4P initiatives underway in Canada at the provincial level.
  • Canadian P4P must utilize regional differences, and Canadian infrastructure to collect data, and learn from other industries.
  • P4P should support a variety of measures.

Significance to Literature:

Summarizes Canadian P4P themes emerging from several commentaries.

 

(122) Knottnerus JA, Velden GHMT. Dutch Doctors and Their Patients—Effects of Health Care Reform in the Netherlands. NEJM. Perspective. 2007: 357(24) 2424-2426.

PMID: 18077806

Summary:

  • In 2006, the Netherlands implemented a new healthcare system, assigning medical primary care physicians to all citizens with mandatory insurance.
  • Over and above the standard capitated payment system, the new system adds fee-for-service payments for more complicated patients.
  • Consumers have responsibility to select the right health plan for self.
  • Physicians must demonstrate their engagement in quality-improvement to obtain financial compensation.
  • This has already benefited general practitioners in low-income areas because it allows for greater compensation for more complex cases.
  • Task force exist that prepares professional guidelines and performance indicators

Significance to Literature:

New Dutch system aims to promote primary care through enhanced payments for more complicated patients.

 

(123) Enthoven AC, Ven WPMMVD. Going Dutch—Managed-Competition Health Insurance in the Netherlands. NEJM. 2007: 357(24) 2421-2423.

PMID: 18077805

Summary:

  • After 20 years of research, in 2006 a new Dutch healthcare system was realized.
  • Mandatory insurance for all citizens, most insurers are private, but are heavily regulated.
  • Risk equalization is a pre-condition of the new system and is based on which patients are predicted to cost more.
  • Individuals and employers must contribute to a risk equalization fund.
  • The “Dutch model” was first designed and proposed for the United States, and similar proposals exist today.

Significance to Literature:

Risk-adjusted capitated medical homes may be a necessary component for P4P. It took the Dutch 20 years of research and a homogenous population to accurately risk-adjust a capitated primary care panel of patients.

 

(149) Hawkes N. How do we get the measure of patient care? British Medical Journal. 2008: 336 249.

PMID: 18244995

Summary:

  • Author agrees with movement to measure quality through process-based measurements.
  • Article outlines Patient Reported Outcome Measures (PROMs), which will help assess quality in care from the patients perspective post-operation.
  • Author warns because of the high number of patients needed to comply, the system, “will add to the noise, without contributing much to the signal.”

Significance to Literature:

Article argues against using death or specific outcome measures in P4P. Suggests limitation of using PROMs in P4P.

 

(154) Majeed A, Lester H, Bindman A. Improving the quality of care with performance indicators. British Medical Journal. Analysis. 2007: 335 916-918.

PMID: 17974688

Summary:

  • Gives reasoning behind P4P, and why measuring performance is important.
  • Although public reporting does not seem to play a role in how patients choose their general practice physician, public reporting does encourage providers to improve quality.
  • Author recommends that internationally accepted data standards and coding would allow for large amounts of data, and comparisons of quality across countries.

Significance to Literature:

Outlines the use of P4P for quality comparisons from the individual clinician to the international level.

 

Key Article

(162) Campbell SM, McDonald R, Lester H. The Experience of Pay for Performance in English Family Practice: A Qualitative Study. Annals of Family Medicine. 2008: 6(3) 228-234.

PMID: 18474885

Summary:

  • Interviewed 20 nurses and 21 family doctors across England to explore beliefs and concerns about changes to service as a result of P4P between 2004-2007.
  • Many doctors and nurses acknowledged that nurses have become the primary provider of health care for patients with chronic disease, however most P4P reimbursements go to doctors.
  • The QOF achieved objectives:
    • Improved disease specific processes of patient care
    • Increased primary care physician income
    • Improved data capture
  • Lists unintended consequences including:
    • Dual QOF-patient agenda within consultations
    • Potential deskilling of doctors
    • Decline in doctor/patient continuity of care
    • Resentment by team member not benefiting financially
    • Concerns about an ongoing culture of performance monitoring

Significance to Literature:

British family doctors and nurses surveyed believe that despite benefits, P4P negatively affects relationships between doctors, nurses, and patients.

 

(163) Mannion R, Davies HT. Incentives in health systems: developing theory, investigating practice. Journal of Health Organization and Management. 2008: 22(1) 5-10.

PMID: 18488515

Summary:

  • Provides and a definition and an overview of P4P.
  • Highlights recent findings/results in other countries.
  • “Need to move beyond case accounts of on-the-surface-successful implementation of P4P schemes to more theoretically driven and analytic evaluations of such schemes in all their diversity.”

Significance to Literature:

Overview of P4P case results in many countries.

 

Key Article

(164) Doran T. Lessons from Early Experience with Pay for Performance. Journal Disease Management and Health Outcomes. 2008: 16(2) 69-77.

Link: http://link.springer.com/article/10.2165%2F00115677-200816020-00001

Summary:

  • Evidence of long-term benefits and harms of the UK’s QOF P4P schemes is beginning to emerge, better health outcomes must be observed to continue P4P.
  • Early reports from the UK are encouraging.
  • Author lists 10 characteristics of successful P4P schemes, and discusses 3 risks associated with P4P that must be examined.

Significance to Literature:

Provides insights, based on data from 2004-2007, about successful and unsuccessful elements of the United Kingdom’s QOF P4P program.

 

(184) Ashworth M, Millett C. Quality Improvement in UK Primary Care: The Role of Financial Incentives. Journal of Ambulatory Care Management. 2008: 31(3) 220-225.

PMID: 18574380

Summary:

  • Article outlines the inception of QOF, its initial outcomes, and how QOF rewards physicians.
  • Discusses QOF as a research tool, and the future directions of QOF.

Significance to Literature:

After a short period of time, QOF has become an instrumental tool to improving quality in the UK, and its role will grow in the coming years.

 

Key Article

(186) Doran T, Fullwood C, Reeves D, Gravelle H, Roland M. Exclusion of Patients from Pay-for-Performance Targets by English Physicians. NEJM. 2008: 359(3) 274-284.

PMID: 18635432

Summary:

  • Article first discusses the three approaches to avoiding inappropriate treatment of patients when a quality indicator does not apply when other considerations must take precedence:
    • Risk-adjust
    • Maximum achievement thresholds
    • Exception reporting
  • Analysis of data from exception reporting in the UK, including financial gain analysis, and the effect of the characteristics of patients and medical practices.
  • The median rate of exceptions in 2005-2006 was 5.3%
  • Authors conclude that exception reporting has brought substantial benefits to P4P in the UK, and there is little evidence of gaming the system.
  • Exceptions accounted for about 1.5% of the cost of the P4P program in the UK.
  • Discusses the arguments for and against exception reporting.

Significance to Literature:

Exclusion of patients is necessary in P4P, this demonstrates a successful attempt to do so.

 

(194) Doran T, et al. Pay-for-Performance Programs in Family Practices in the United Kingdom. NEJM. 355(4) 375-384.

PMID: 16870916

Summary:

  • Analyzed data from the NHS from April 2004-March 2005 about the use of clinical indicators amongst the entire population, and determined the extent to which exception reporting utilized.
  • Exception reporting was not extensive, but it was the strongest predictor of achievement. A 1% increase in exception reporting correlated with .31% increase in reported achievements.
  • Exception reporting was high in only a small amount of practices.

Significance to Literature:

A small number of practices appear to have achieved high scores by excluding a large number of patients by exception reporting.

 

(201) Perkins R, Seddon M. Quality Improvement in New Zealand healthcare. Part 5: measurement for monitoring and controlling performance—the quest for external accountability. The New Zealand Medical Journal. 119(1241).

PMID: 16964301

Summary:

  • The key audience for report cards and public reporting seems to be provider organisations, not patients or the public at large.
  • Performance data is very complex, and that must be recognized when using performance indicators.
  • All performance indicators give rise to some form of perverse or unintended consequence. Article lists some of these possible consequences.

Significance to Literature:

Serious pitfalls of performance indicators must be addressed in New Zealand’s performance indicators and public report cards.

 

(209) Campbell S, et al. Quality of Primary Care in England with the Introduction of Pay for Performance. NEJM. 2007: 357(2) 181-190.

PMID: 17625132

Summary:

  • Study of 42 physicians practices in England tracking performance indicators from 1998, 2003 (both pre-P4P), and 2005 (with P4P). Authors compared trends in 30 indicators with financial incentives, and 17 indicators without.
  • The quality of performance for indicators with financial incentives in coronary heart disease, type 2 diabetes, and asthma was substantially higher than those performance indicators without incentives.
  • However, scores did not differ significantly from trend rate predicted performance scores.

Significance to Literature:

Results show modest acceleration of quality improvement for diabetes and asthma.

 

(211) Roland M. Linking Physicians’ Pay to the Quality of Care—A Major Experiment in the United Kingdom. NEJM. 2004: 351(14) 1448-1454.

PMID: 15459308

Summary:

  • Detailed summary of the Quality and Outcomes Framework, P4P in the United Kingdom.

Significance to Literature:

Objective overview of the P4P program in the United Kingdom in 2004.

 

(227) Wilson JF. Lessons for Health Care Could Be Found Abroad. Annals of Internal Medicine. 2007: 146(6) 473-476.

PMID: 17371900

Summary:

  • In 2001, the Organization for Economic Co-operation and Development (OECD) launched the Health Care Quality Indicator (HCQI) project, a 23 country collaboration, to formalize data collection and reporting worldwide in hopes of using the data to learn ways to improve quality care across countries.
  • Countries include UK, US, Canada, Australia, Denmark, France, Germany, Japan, Mexico, and the Netherlands.
  • The use of EMRs will greatly help data collection.

Significance to Literature:

Learning from other countries will be an important way to improve quality of care, and P4P programs.

 

(229) Duckett S, et al. Pay for Performance in Australia: Queenland’s new Clinical Practice Improvement Payment. Journal of Health Services Research & Policy. 2008: 13(3)174-177.

PMID: 18573767

Summary:

  • Queensland, Australia is implementing a new P4P system called Clinical Practice Improvement Payment system (CPIP) that rewards hospitals for achievement of clinical process indicators.
  • Physician skepticism reinforces the importance of clinician involvement in measurement development.
  • CPIP is not universally endorsed, however, Australia is now making a concerted effort to involve physicians about measurement development.

Significance to Literature:

“P4P in Australia appears to be gaining widespread, if somewhat reluctant, acceptance.”

 

(242) Satin DJ. Paying Physicians and Protecting the Poor. Minnesota Medicine. Commentary. 2006 Apr;89(4):42-4. 

PMID: 16681283

Summary:

  • “Adjust performance goals to account for the socioeconomic status of patients and allow for limited exceptions to the program.”
  • P4P programs must realize that patients have many determinants of health, and that as little as 10% of their health status can be based on their health provision.
  • P4P in New Zealand and the United Kingdom have devised ways to risk adjust.

Significance to Literature:

P4P programs must risk adjust in order to accurately assess physician performance.

 

(253) Smylie J, Anderson I, Ratima M, Anderson M. Indigenous health performance measurement systems in Canada, Australia, and New Zealand. The Lancet. Viewpoint.  2006: 367 2029-2031.

PMID: 16782494

Summary:

  • Article discusses how performance measurements may be troublesome in indigenous populations in Canada, Australia, and New Zealand.
  • Primarily, indicators are nationwide quality markers, and not good markers of quality within indigenous communities possibly due to different health beliefs.
  • Authors suggest that, in hopes of engaging health care communities most effectively, performance markers should be set by local communities.

Significance to Literature:

Suggest unique approach to quality improvement for indigenous peoples.

 

(283) Scott IA. Pay for performance programs in Australia: a need for guiding principles. Australian Health Review. 2008: 32(4) 740-749.

PMID: 18980570

Summary:

  • Paper outlines 10 principles for success for P4P programs derived from a review of published trials, program evaluations, and position statements:
  •    1. Formulate rationale and business case
  •    2. Use established evidence-based performance measures
  •    3. Use rigorous and verifiable methods of data collection and analysis
  •    4. Define performance targets using absolute and relative thresholds
  •    5. Use rewards that are sufficient, equitable, and transparent
  •    6. Address appropriateness of provider responses and avoid perverse incentives.
  •    7. Implement governance procedures which incorporate communication and feedback strategies
  •    8. Use existing structures to implement P4P programs.
  •    9. Attribute credit for performance to participants in ways that foster population-based perspectives
  •    10. Invest in outcomes and health service research

Significance to Literature:

Overview of literature suggestions for P4P program implementation

 

(284) Cupples ME, Byrne MC, Smith SM, Leathem CS, Murphy AW. Secondary prevention of cardiovascular disease in different primary healthcare systems with and without pay-for-performance. Heart. 2008: 94 1594-1600.

PMID: 18701532

Summary:

  • Analyzes baseline cardiovascular care in the United Kingdom (P4P) versus Northern Ireland (No P4P). Assesses how P4P may factor into the quality of care.
  • A strong, publicly funded healthcare systems, like Northern Ireland's, may manage risk factors well, but patients still have less healthy lifestyles and poorer quality of life. In contrast, the United Kingdom has a mixed healthcare economy, and relatively healthier lifestyles.
  • Prevention measures may have different impacts on populations depending on the nature of the healthcare system.

Significance to Literature:

One cannot simply import successful P4P measures from another healthcare system and expect similar results.

 

(293) Rubenstein A, et al. A Multimodal Strategy Based on Pay-Per-Performance to Improve Quality of Care of Family Practitioners in Argentina. Journal of Ambulatory Care Management. 2009: 32(2) 103-114.

PMID: 19305222

Summary:

  • Reports results after 2 years of instituting a Quality Improvement program in Buenos Aires that utilizes P4P, teamwork, continuous education, and audit and feedback.
  • Primary Care groups earn up to a 1000 points in the system from a complex set of indicators made up of each of the five categories above.
  • A significant improvement in all indicators related to clinical effectiveness was achieved.
  • A ceiling effect of scores was observed.

Significance to Literature:

P4P as being only one part of a QI program may be another way to utilize financial incentives.

 

(298) Babic M. Pay-for-performance planned for SMH. Canada.com. March 3, 2009.

Link: http://www2.canada.com/surreynow/news/story.html?id=c7ee28a6-5d54-4ecf-8...

Summary:

  • In Canada, Surrey Memorial Hospital is beginning a P4P program that aims to reduce wait times in the hospital.
  • The hospital will receive bonus payments for getting patients either discharged or admitted in less than certain allotted amounts of time.

Significance to Literature:

P4P is being used to reduce waiting times and improve efficiency.

 

(306) Custers T, Arah OA, Klanzinga NS. Is there a business case for quality in The Netherlands? A critical analysis of the recent reforms of the health care system. Health Policy. 2007: 82 226-239.

PMID: 17070956

Summary:

  • Analysis of new reimbursement program in the Netherlands.
  • Authors argue that new P4P program only advocates efficiency, and not bettering quality of care.
  • Discussion of the free market environment of healthcare and its limitations.

Significance to Literature:

The current market trends in healthcare limit the ability of P4P to impact quality of care provided.

 

(438) Qureshi N, Weng S, Hex N. The role of cost-effectiveness analysis in the development of indicators to support incentive-based behaviour in primary care in England. J Health Serv Res Policy. 2016 May 20. pii: 1355819616650912. [Epub ahead of print]

PMID: 27207081

Summary:

  • Description of the methods developed to evaluate cost-effectiveness of P4P indicators within England’s Quality and Outcomes Framework (QOF)
  • An economic subgroup of the National Institute for Health and Care Excellence (NICE) Indicator Advisory Committee convenes quarterly to:
    • Suggest new clinical or public health indicators
    • Evaluate outcomes of pilot programs and cost-effectiveness of new indicators
    • Review current performance indicators and recommend retirement or changes
    • Assess payment amounts to practices for achieving new indicators
  • New indicators eligible for economic appraisal include those which:
    • Lead to specific treatment or therapy
    • Have clinically significant outcomes or are surrogates for clinically significant outcomes
    • Have relevant and robust data on cost-effectiveness
  • Current policy to reduce QOF funding will make effective evaluation of  indicator cost-effectiveness more important than ever

Significance to Literature:

Economic appraisal of future and current performance indicators in a pragmatic and effective way is vital for informing recommendations on P4P measures

 

Key Article

(447) Roland M, Olesen F. Can pay for performance improve the quality of primary care? BMJ. 2016 Aug 4;354:i4058. doi: 10.1136/bmj.i4058.

PMID: 27492822  

Summary:

  • Analysis of what other countries can learn from the United Kingdom’s experience with the Quality and Outcomes Framework (QOF)
  • Recommendations from Roland and Olesen for P4P program development and introduction include:
    • Determine the appropriate number of quality indicators for the nature and scale of the scheme setting
    • Providers who will be assessed by the quality indicators should be involved in choosing the measures, with only those indicators with a strong evidence base or widespread expert consensus being considered
    • Exception reporting should be allowed but closely monitored
    • Unintended consequences are unavoidable in any incentive scheme but these should be anticipated and continuously monitored

Significance to Literature:

Lessons learned from the UK’s experience with QOF should influence current and future P4P programs, with P4P being a part of a wider quality improvement effort due to its seemingly modest effects on quality

 

(448) Ruscitto A, Mercer SW, Morales D, Guthrie B. Accounting for multimorbidity in pay for performance: a modelling study using UK Quality and Outcomes Framework Data. Br J Gen Pract.2016 Aug;66(649):e561-7. doi: 10.3399/bjgp16X686161. Epub 2016 Jul 5.

PMID: 27381486

Summary:

  • P4P schemes such as United KIngdom’s Quality and Outcomes Framework (QOF) are largely designed around individual diseases which can result in payment variation for the same incentivized action in patients with multiple comorbidities (i.e. a single clinical action may attract multiple payments in some patients)
  • Modelling study was performed by calculating maximum payments practices could receive using existing QOF incentives for blood pressure control (≤150/90 mmHg) and influenza immunization in patients with multimorbidity
    • Payments were then recalculated with a single indicator that ensured each incentivized action was only paid for once (based on method previously used with smoking indicators in QOF)
  • Results from modelling included:
    • Multiple payments for a single clinical action were made in one-fifth of patients incentivized for influenza immunization and one-third of patients incentivized for blood pressure control
    • Variation in payment was present for patients with a single comorbidity (greater than 2-fold) but was significantly increased with multiple payments for patients with multimorbidity (up to approximately 7-fold)
    • For influenza immunizations, recalculations with clinical action only being paid once resulted in more funding for the most affluent practices (+7.2%), with the most deprived practices losing up 6.2% of original payments
    • Blood pressure control results showed loss of payments for all practices but with the most deprived practices losing the highest percentage of payment (12.2%)

Significance to Literature:

Study authors indicate designers of P4P schemes like QOF should be more clear about whether financial incentives are intended to reflect actual workload or expected benefit to patients. These payment systems must be adequately modeled before implementation to ensure they deliver their intended aims.