Opinion

Why pay-for-performance schemes are destined to fail


Dr Edwin Kruys 10/11/2017 2:02:17 PM

Australia has a track record of flirting with healthcare reform ideas that have failed overseas. The latest hype seems to be about performance indicators, targets and pay-for-performance.

News teaser

It is tempting to pay doctors when their patient, for example, has a lower blood pressure, loses weight or improves sugar levels. However, pay-for-performance schemes have been tried elsewhere in the world with disappointing results.
 
For example, performance management has gone wrong in the British Quality and Outcome Framework pay-for-performance system and resulted in:

  • only modest – and often not long-lasting – improvements in quality
  • decreased quality of care for conditions not prioritised by the pay-for-performance system
  • no reduction of premature mortality
  • loss of the patient-centeredness of care
  • reduced trust in the doctor–patient relationship
  • reduced access to GPs
  • decreased doctor morale
  • billions of pounds in implementation costs.
As Goodhart’s law says: ‘When a measure becomes a target, it ceases to be a good measure’.
 
Primary care is a complex system. Quality improvement processes that are traditionally applied to linear mechanical systems, like isolated single-disease care, are not very useful for complex systems.
 
There is now a trend away from performance-management schemes In the UK and Scotland. We need to test new models of care in the Australian context, but we must avoid making the mistakes others have made before us.


THE AUTHOR:


healthcare-reformpay-for-performance

British GP working in Perth WA - Bulk billing practice in low socioeconomic demographic
Comments above refer to being money should not be the motivation - Clinical performance targets for income ..surely not? What about clinical intervention with little or no evidence of clinical cost / benefit which increase Australian GP/ specialist income such as Iron infusions that currently take place.
I'm an ex NHS GP, and worked in a very practice with high QOF points. This can only be achieved by accurate disease registers, excellent software monitoring clinical indicators, recall systems etc The impact of QOF is complex, and both in measurable and non measurable outcomes. Whilst it did interfere with the Dr Pt relationship, as Drs are focused on ensuring the QOF templates are updated, it also promoted a standardization of care delivered based on evidence. For example 600 DM's at my practice in the majority we achieved HBa1c , BP and Lipids to target with consistent review and re auditing, such that we only had 22 patients where ALL indicators were below target. the exception coding was used ethically to exclude patients where targets were clinically inappropriate..QOF frameworks and the data recording allowed us to create a systematic DM review clinic with structure that was much more focused. Our model was then " borrowed" by a pharmaceutical company and rolled out as an example of how care can be organised. eg it was great being able to code things such as
Statin not tolerated or
Statin declined
because it created more efficient conversations in future consultations, as one doesnt have to repeat the questions/ trials of medications.
As a comparison here in WA Australia I see pharmaceutical industry influenced prescribing and education, lack of adherence to evidence based clinical guidelines, and lack of consistent standards of care to best practice. Many British GPs here are shocked by the huge variability in clinical standards and no accountability or systematic clinical governance.
I am shocked by the poor record keeping I have seen here in WA/ and poor data entry, Best Practice is inadequate and one cannot run even run reliable audits. The system here is unsafe with " Dr shopping " resulting in multiple clinical records and lack of continuity of care. Long waiting lists for public health if the patient doesnt have insurance. The problem with the NHS is it relies on the goodwill of staff working within it working at break neck speed to deliver the care.
Chronic disease management requires reliable medical records and continuity of care, a tax payer funded health system needs to ensure interventions are evidence based, and cost effective, ( Dr shopping completely undermines this)
Concerns about patient who " do not comply " and potentially cause loss of income are raised because those Drs have not worked in the QOF system and would not be aware of the exemption coding and other adjustments practices were awarded where the population had high deprivation scores. It was complicated !
30/11/2017 1:38:17 PM

Tania
Having been a patient (victim) of the NHS this year, I can only say that Australian health care will definitely not benefit if we go down that track
12/11/2017 7:52:43 PM

Robin
I worked in the UK with QOF. It was terrible. Tick box, disease focussed medicine with computer programs telling you what to do to maximise your profit. It really detracted from good patient centred medicine and demanded an enormous amount of work on following up all those who hadnt had their boxes ticked, usually just to click on the exempt box because of some reason or other. The doctor spends the whole consult focussed on the computer, the patient is unhappy and the health improvement outcomes as you have read above are very unimpressive. This micromanagement of the consult brings the politician into the consulting room and they sit right beside you. GPs do a better job when trusted and left to utilise their humane gifts within the consult. Let the patient and their GP set the agendas!
11/11/2017 8:29:57 AM

Steve
I think there are too many factors to correct for to implement this fairly.

For example a GP in an area with an affluent well educated demographic can send a patient with cardiac risk factors straight to a private cardiologist where they will get preventative treatment early and excellent follow up and education with minimal work on the GPā€™s behalf. In lower SES areas the same patient presents later, spends a long time wait listed for a public hospital angiogram and may have a heart attack before receiving preventative care despite the GP having potentially invested hours in trying to manage and educate the patient. I have experienced this in my own practice.

I also find the idea a little insulting that we need to be motivated with money to actually try to get the best outcomes for our patients.
10/11/2017 10:48:35 PM

Milan
I worked as GP in Germany 5 years in my own surgery. These measurements are intended to make the GP telling the patient " Suck it up sunshine". The plan is to split the mutual beneficial relationship of GP and patient for the sake of third laughing party: medicare saving money. Dont forget: patients just cost and are not productive.
10/11/2017 4:44:45 PM

Dr Henri Becker
Ed , the Payor has not yet made the difference between disease management and case management
I have 20 years of experience in reducing cost and improving quality of care for the multiple chronically ill
Please contact me if you are interested in discussing further
10/11/2017 3:22:39 PM

Petronella ( Elly) Slootmans
I don't believe GP's improve patients health. We advise. It is the patient who has to implement the recommendations and it is patient motivation and understanding of their health which then improves compliance which will ultimately improve outcomes. We need to make patients responsible for outcomes not just GP's. If patients had to undergo the same kind of compliance measures as GP's we would get the results we are looking for.
10/11/2017 1:28:10 PM

Noela Whitby
Perhaps the incentives should be directed at patients for taking responsibility for achieving healthy outcomes - why is it just our responsibility to improve outcomes -'you can take a horse to water but you can't make it drink ! '
10/11/2017 1:03:53 PM

Eileen Davies
Pay for performance is absurd.
Obviously a fat smoking diabetic with bronchitis will not do well. Not the doctors fault.
No doctors will want to treat patients, such as addicts, who won't help themselves, as their poor outcome is THEIR fault not the poor GPs.
10/11/2017 12:57:51 PM

Ewen McPhee
The current conversation is about quality improvement, that requires data to understand current practice data and comparison with peers. I haven't seen anyone talking about Pay for Performance.
10/11/2017 12:33:15 PM

So what is the solution?
So what does the author suggest to incentivise GPs to improve their active management of patients? Or should we stick to reactive transnational medicine?
10/11/2017 9:40:32 AM

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