The United Kingdom's nascent experience with pay for performance may hold
some lessons for physicians and policymakers in the United States.
Family practices in England were highly successful in meeting indicators
for quality of care during the first year of a new pay-for-performance
contract with the nation's National Health Service, according to a report in
the July 27 New England Journal of Medicine.
According to the report, family practices met a median 83.4 percent of
quality indicators. However, a small number of practices appear to have
achieved high scores through "exception reporting"—the
exclusion of large numbers of patients from quality reporting.
Lead author Tim Doran, M.P.H., and colleagues at the University of
Manchester's National Primary Care Research and Development Centre, found that
sociodemographic characteristics of the patients and practices had moderate
but significant effects on performance.
Sociodemographic characteristics of practices included size of practice,
number of patients per practitioner, age of practitioner, and whether the
practitioner was medically educated in the United Kingdom.
The median rate of exception reporting was only 6 percent, but it was the
strongest predictor of achievement: a 1 percent increase in the rate of
exception reporting was associated with a 0.31 percent increase in reported
achievement. Exception reporting was high in a small number of practices: 1
percent of practices excluded more than 15 percent of patients.
The U.K. pay-for-performance contract allows family practitioners to
exclude patients from eligibility for specific indicators in the performance
calculations. Legitimate reasons for excluding patients from reporting include
Moreover, as the report noted, exception reporting also provides an
opportunity for family practitioners to increase their income by
inappropriately excluding patients for whom they have missed the targets (a
practice known as gaming).
In 2004, after a series of national initiatives associated with marked
improvements in the quality of care, the National Health Service of the United
Kingdom introduced a pay-for-performance contract for family practitioners.
This contract increases existing income according to performance with respect
to 146 quality indicators covering clinical care for 10 chronic diseases,
organizationof care, and patient experience.
Doran and colleagues analyzed data extracted automatically from clinical
computing systems for 8,105 family practices in England in the first year of
the pay-for-performance program (april 2004 through March 2005), data from the
U.K. Census, and data on characteristicsof individual family practices. They
examined the proportion of patients deemed eligible for a clinical quality
indicator for whom the indicator was met (reported achievement) and the
proportionof the total number of patients with a medical condition for whom a
quality indicator was met (population achievement).
They used statistical analysis to determine the extent to which practices
achieved high scores by classifying patients as ineligible for quality
indicators (exception reporting).
In an editorial accompanying the report, Arnold Epstein, M.D., pointed out
that British family physicians received additional salary payments averaging
more than $40,000 per physician in the program's initial year as a result of
the high achievement—a factor that led to a budget deficit for the
National Health Service.
"The high level of performance, which has contributed to the National
Health Service deficit, 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," he wrote.
Epstein is with the Department of Health Policy and Management at Harvard
School of Public Health and the Division of General Medicine at Brigham and
Woman's Hospital in Boston.
"The study... reminds us that policy changes may lead to unexpected
consequences, such as the higher payments to doctors by the National Health
Service, which have resulted in increased budget deficits," Epstein
wrote. "Perhaps the most important lesson we can take from the
experience in the United Kingdom would be to consider carefully the myriad
potential consequences of pay for performanceand to monitor the implementation
of such a program carefully."
An abstract of "Pay-for-Performance Programs in Family
Practices in the United Kingdom" is posted at<http://content.nejm.org/cgi/content/abstract/355/4/375>.▪