Pay-for-Performance Programs in the United Kingdom
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《新英格兰医药杂志》
To the Editor: As a general practitioner in England, I and the practice in which I work were directly affected by the changes made in 2004 by the introduction by the National Health Service of a pay-for-performance contract for family practitioners, as reported by Doran and colleagues (July 27 issue).1 The contract was evidence based, ensuring that the majority of general practitioners approved of its aims.
Doran and colleagues omitted a number of important lessons that can be drawn from that experience. First, the necessity to "tick boxes" to ensure that tasks triggering payment were completed had a major effect on many consultations each day. Second, much bigger than the payments to general practitioners were the increased consequential costs triggered by the quadrupling of prescriptions for statins. Third, there was the effect on the local hospitals of a sudden increase in referrals for investigative procedures such as echocardiography for heart failure and cardiologic referrals for angina — conditions that previously had often been dealt with without referrals. Fourth, there is the increased medication load for patients — typically, a patient with diabetes has to take 10 different therapies.
Andrew A.F. Sanderson, M.B., B.S.
St. Andrew's Medical Practice
Spennymoor DL16 6QA, United Kingdom
andrew.sanderson@gp-a83001.nhs.uk
References
Doran T, Fullwood C, Gravelle H, et al. Pay-for-performance programs in family practices in the United Kingdom. N Engl J Med 2006;355:375-384.
To the Editor: In his editorial accompanying the article by Doran and colleagues, Epstein1 encourages the United States to adopt a system similar to that introduced in the United Kingdom. Although financial incentives could change doctors' behavior,2 it is difficult to ascertain whether the achievement reported by Doran et al. is due solely to incentives or to an improvement in clinical practice in general, since there is no control group and there are no baseline data. In our area, organizational care indicators for diabetes, such as data recording, have increased dramatically, but clinical indicators, such as cholesterol levels and glycated hemoglobin values, have revealed a smooth increase that might be due to other factors, such as the use of national targets and the active dissemination of guidelines. Pay for performance could result in a loss of the holistic approach to patient care,3 and patients with diseases that are not included in the contract could be put at a disadvantage.3 Incentives may need to increase with time to maintain targets. Pay for performance may be a good idea, but it should be implemented with caution. We would recommend that when this approach is introduced into a new area it be started as a pilot, so that some comparisons with conventional care as a control can be made.
Abd A. Tahrani, M.D., M.R.C.P.
Royal Shrewsbury Hospital
Shrewsbury SY3 8XQ, United Kingdom
abdtahrani@yahoo.co.uk
George I. Varughese, M.R.C.P.
University Hospital of North Staffordshire
Stoke-on-Trent ST4 6QG, United Kingdom
Andrew F. Macleod, M.D.
Royal Shrewsbury Hospital
Shrewsbury SY3 8XQ, United Kingdom
References
Epstein AM. Paying for performance in the United States and abroad. N Engl J Med 2006;355:406-408.
Chaix-Couturier C, Durand-Zaleski I, Jolly D, Durieux P. Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues. Int J Qual Health Care 2000;12:133-142.
Roland M. Linking physicians' pay to the quality of care -- a major experiment in the United kingdom. N Engl J Med 2004;351:1448-1454.
The editorialist replies: I agree in general with Tahrani et al. As noted in my editorial, the findings reported by Doran et al. could reflect a number of different factors other than improved performance as prompted by the payment incentives. And surely there are a number of reasons to have modest expectations for the improvement in quality associated with pay-for-performance programs and to be wary of the potentially deleterious side effects they may inspire. There have been relatively few studies of pay for performance in health care.1,2 On the whole, their findings are not encouraging, although most of the programs studied may not be comparable to the large efforts now envisioned. Numerous pay-for-performance programs are under way in the private sector, and although few have been formally analyzed, anecdotal information has not pointed to large negative consequences. Many aspects of pay for performance make intuitive sense. Thus, it seems to me to be reasonable to bolster efforts in this direction, so long as we maintain moderate expectations and monitor the programs carefully, with an eye to making appropriate modifications.
Arnold M. Epstein, M.D.
Harvard School of Public Health
Boston, MA 02115
References
Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA 2005;294:1788-1793.
Rosenthal MB, Frank RG. What is the empirical basis for paying for quality in health care? Med Care Res Rev 2006;63:135-157.
Doran and colleagues omitted a number of important lessons that can be drawn from that experience. First, the necessity to "tick boxes" to ensure that tasks triggering payment were completed had a major effect on many consultations each day. Second, much bigger than the payments to general practitioners were the increased consequential costs triggered by the quadrupling of prescriptions for statins. Third, there was the effect on the local hospitals of a sudden increase in referrals for investigative procedures such as echocardiography for heart failure and cardiologic referrals for angina — conditions that previously had often been dealt with without referrals. Fourth, there is the increased medication load for patients — typically, a patient with diabetes has to take 10 different therapies.
Andrew A.F. Sanderson, M.B., B.S.
St. Andrew's Medical Practice
Spennymoor DL16 6QA, United Kingdom
andrew.sanderson@gp-a83001.nhs.uk
References
Doran T, Fullwood C, Gravelle H, et al. Pay-for-performance programs in family practices in the United Kingdom. N Engl J Med 2006;355:375-384.
To the Editor: In his editorial accompanying the article by Doran and colleagues, Epstein1 encourages the United States to adopt a system similar to that introduced in the United Kingdom. Although financial incentives could change doctors' behavior,2 it is difficult to ascertain whether the achievement reported by Doran et al. is due solely to incentives or to an improvement in clinical practice in general, since there is no control group and there are no baseline data. In our area, organizational care indicators for diabetes, such as data recording, have increased dramatically, but clinical indicators, such as cholesterol levels and glycated hemoglobin values, have revealed a smooth increase that might be due to other factors, such as the use of national targets and the active dissemination of guidelines. Pay for performance could result in a loss of the holistic approach to patient care,3 and patients with diseases that are not included in the contract could be put at a disadvantage.3 Incentives may need to increase with time to maintain targets. Pay for performance may be a good idea, but it should be implemented with caution. We would recommend that when this approach is introduced into a new area it be started as a pilot, so that some comparisons with conventional care as a control can be made.
Abd A. Tahrani, M.D., M.R.C.P.
Royal Shrewsbury Hospital
Shrewsbury SY3 8XQ, United Kingdom
abdtahrani@yahoo.co.uk
George I. Varughese, M.R.C.P.
University Hospital of North Staffordshire
Stoke-on-Trent ST4 6QG, United Kingdom
Andrew F. Macleod, M.D.
Royal Shrewsbury Hospital
Shrewsbury SY3 8XQ, United Kingdom
References
Epstein AM. Paying for performance in the United States and abroad. N Engl J Med 2006;355:406-408.
Chaix-Couturier C, Durand-Zaleski I, Jolly D, Durieux P. Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues. Int J Qual Health Care 2000;12:133-142.
Roland M. Linking physicians' pay to the quality of care -- a major experiment in the United kingdom. N Engl J Med 2004;351:1448-1454.
The editorialist replies: I agree in general with Tahrani et al. As noted in my editorial, the findings reported by Doran et al. could reflect a number of different factors other than improved performance as prompted by the payment incentives. And surely there are a number of reasons to have modest expectations for the improvement in quality associated with pay-for-performance programs and to be wary of the potentially deleterious side effects they may inspire. There have been relatively few studies of pay for performance in health care.1,2 On the whole, their findings are not encouraging, although most of the programs studied may not be comparable to the large efforts now envisioned. Numerous pay-for-performance programs are under way in the private sector, and although few have been formally analyzed, anecdotal information has not pointed to large negative consequences. Many aspects of pay for performance make intuitive sense. Thus, it seems to me to be reasonable to bolster efforts in this direction, so long as we maintain moderate expectations and monitor the programs carefully, with an eye to making appropriate modifications.
Arnold M. Epstein, M.D.
Harvard School of Public Health
Boston, MA 02115
References
Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA 2005;294:1788-1793.
Rosenthal MB, Frank RG. What is the empirical basis for paying for quality in health care? Med Care Res Rev 2006;63:135-157.