Pay-for-Performance in the UK

The idea behind pay-for-performance makes sense–reward physicians and other providers for rendering care that improves outcomes.  The reality has been mixed.  A health policy report in the New England Journal of Medicine reviews the Quality and Outcomes Framework program, which has been operating in the United Kingdom for over ten years.  (NEJM Article)  Under the original conception of that program, a quarter of primary care doctors’ pay was tied to measures of performance, including organizational factors, patient satisfaction and actual health care delivery.  One reason for the program was to significantly increase primary care pay, which was lagging and causing fewer doctors to go into primary care.  Pay did increase, but the “performance” aspects of the program have been decidedly mixed.  Process of care measures for chronic diseases generally showed improvement since initiation of the program, but they were improving rapidly before it started and there were a variety of other quality improvement efforts which may also have been responsible for the gains.  Continuity of care and patient satisfaction showed little to no improvement.

And physicians, while they were happy with the extra pay, began to feel less job satisfaction, perceiving the program to be a distraction and to actually lessen their attention to holistically treating the patient, instead focusing on documentation and checklists during the visit.  The structure of practices also changed, with greater use of EHRs, more nursing staff who took care of managing the chronic disease patients, and more administrative staff to track data related to improvement.  Due to physician dissatisfaction or lack of experiential utility, some measures have been dropped, including organizational ones and patient experience surveys.  Currently, indicators have been added for managing specialist referrals, unscheduled hospital admissions and proactive case management for vulnerable elderly patients.  The biggest “unintended” consequence, which really most people knew was likely to occur, is that doctors naturally tend to pay most attention to what they are financially invented to measure, which means that other important aspects of patient care or health needs may get neglected.  The pay available under the program has been reduced, and other aspects are being reviewed to try to create a more balanced and less burdensome and intrusive effect on medical practice.  All good lessons for the United States.