Performance incentive schemes in high-income countries Overview

Performance incentives in the high income countries – key

issues and lessons learned (for the low-income countries)

Riku ElovainioWorld Health Organization, Geneva

INCENTIVE SCHEMES AND PERFORMANCE OFHEALTH CARE PROVIDERS IN LICS …

Clermont-Ferrand – 17 Dec 2009 (Session 5)

INCENTIVE SCHEMES AND PERFORMANCE OF

HEALTH CARE PROVIDERS IN LICS… | Clermont-Ferrand, 17 December 20092 |

Performance incentive schemes in high-income countries

Overview



Performance Incentives in HICs and LICs – same underpinning

Performance Incentives in HICs and LICs – same underpinning

Performance Incentive (PI) schemes in high-income countries (HICs) have a similar history than in low-income countries (LICs) = implemented mainly in 2000's

Same rationale : direct payment incentive to influence provider behaviour

= same underpinnings than in LIC : (principal-agent relationship and the effect of extrinsic motivation)

BUT – a lot of differences: different context, different objectives different implementation strategies and mechanisms



Explicit incentives that add to the system (implicit) incentives

Often linked with other reforms (ex. public reporting)

Bottom-up approach (projects, programmes) for changing provider behaviour

System wide ambitions only in UK (maybe France)

Performance Incentives in high-income countries – the basics

Performance Incentives in high-income countries – the basics



Overview – Where are the experiences ?Overview – Where are the experiences ?

USA – P4P "movement" related to a reaction to the IOM report "Crossing the

Quality Chasm" (2001)– US patchwork context – P4P schemes have taken several forms – Ex. CMS has several different programs; IHA in California; Bridges to

Excellence; several smaller schemes – In total 248 P4P schemes with different scope, different target and different

indicators (some providers are involved in several schemes at once)

UK– QOF = Quality and Outcomes Framework (2004)– Targeted to primary care practices– National scheme - voluntary (almost 100% adhesion by Y3)– Measures: Clinical (65%); administrative (practice organization); patient

experience; additional (contraceptive use, maternal and child health quite a difference with LIC where these are primary targets)



Australia– PIP – Practice Incentive Programme for GPs (since 1990's)– No aggregate score – each domain is separate– Has not been adopted by GPs – complicated mechanism

France– CAPI (Contrat d'Amélioration des Pratiques Individuelles)– April 2009– Voluntary contract between the SHI and the GPs

Netherlands (insurance companies); Spain (staff incentives); Sweden (service contracts), etc.

Elsewhere?Elsewhere?



Performance Incentives in health – not much happening in HICs?

Performance Incentives in health – not much happening in HICs?

It seems that quite little happening outside a handful of countries …

… but health workers in private and public sectors have been influenced by the general result based reward system (most OECD countries)

– Sectoral strategies in health have been implemented – not always a success

Also, in HICs more maybe happening at the micro level



Who are targeted?Who are targeted?

Individual physicians (CAPI)

Primary Care practices, physician networks (QOF, PIP)

Hospitals (PHQID, IHA, etc.)



Focus on quality of care in HICsFocus on quality of care in HICs

HICs = general context of high utilization of health services basic difference with LICs

High demand (social protection) but also supply (use of FFS payment mechanisms)…

… but studies showing that only ~50% of patients get adequately treated (in the USA) – also big variations in care (Fisher et al., 2002) (business as usual does not work)

PI schemes = mitigation of the payment system incentives – from quantity to quality (from curative to prevention)



How is "quality" measured?How is "quality" measured?

Clinical quality– Process indicators – adherence to care protocols (asthma,

diabetes, coronary heart disease)– Intermediary outcomes (ex. blood pressure results for

hypertensive patients) – (Outcomes) (patient mortality rates)

Patient experience– Surveys– Consultation length

Administrative processes – Record keeping – IT technology use



Has it worked?Has it worked?

Source: Campbell et al. 2007

UK QOFCMS PHQID

… but also some doubts:"too little impact on provider behavior and not enough focus on demonstrable benefit — including both health outcomes and spending" (Rosenthal 2008)

Some positive results …

… Petersen et al. 2006 : 12 /15 evaluation studies reported positive results …



Gaming, fraud, unwanted effects?Gaming, fraud, unwanted effects?

There is little evidence of gaming or fraud from the HIC schemes

Ex. in UK QOF the exemptions are seen as a possibility for gaming but little evidence – some evidence on un-normally high exemption rates (but not consistently) (Gravelle et al. 2007)

Patient dumping in USA – some concerns but no evidence (Rosenthal et al. 2007)

No clear evidence on focusing on rewarded aspects of care

When the income of the provider is already level the gain from fraud is relatively little; and the fear of sanction is relatively high



Some lessons learned



Get the incentive path right Get the incentive path right

The PI schemes have been sometimes implemented in a way that leaves the incentive path unclear

– It is not always clear who should benefit • Ex. the QOF targets practices, the nurses do quite a lot of the (routine) work

that affect the score but the GPs get the rewards This has been creating some resentment among the nursing staff Not enough going to investments

In a larger organization (Hospital) several methods for translating the incentives to staff have been used without any clear evidence of which is the best

• Very rarely an individual bonus (or only to some key managers)• Usually based on tightening of monitoring (sanctions)• Most importantly : it is about informing everybody



Who chooses the indicators?Who chooses the indicators?

How to get a good deal (– good deal for who?):– the QOF was a victory for the GPs (for the GP negotiators) good

for GP income; results did follow; but is this value for money? – In some US schemes providers have been less advantaged; some

schemes are cost-neutral from the payments point of view = providers put some of their income at risk (and it worked) better deal for the payer (and it worked also); but will this work in the long run?

– The French CAPI was not thoroughly negotiated with the GP representatives (as QOF), we don't know yet what will happen but it

The way the PI scheme is negotiated will have an impact on the way it works

But negotiations are the only way to get the providers to buy into the system – there is quite a lot of resistance within providers – and the schemes are voluntary



How much should be paid?(how to finance the LIC schemes in the future?)

How much should be paid?(how to finance the LIC schemes in the future?)

Performance incentives are not related to cost containment (at least not immediately)

QOF: in average £1bn/year (£17 pounds per hab.); ~£30 000 per GP (20-25% of GP earnings from QOF) – explicit objective to raise GP income

USA: payments in average 1-2% of total reimbursements = 17$ /insured /month

Big variations in the levels of payment – successful schemes with low payments (PHQID) and high levels (QOF) - no clear evidence on how much is enough – it seems that public reporting has a similar effect than performance incentives

Also some evidence from LIC that money is not the (only) mover



Cost scenariosCost scenarios

Cost increase Cost neutral

Return on investment

Reallocation between interventions or providers"New money"; Ex. QOF



Bonus optimization – return on investmentBonus optimization – return on investment

Optimal reward = $175 /patient/Y

Physician bonus= $4300

1.5 $million net benefit

Bridges to Excellence 2003-208, Five Years on : Bridges Built, Bridges to Build

Using P4P to improve diabetes care

Based on the hypothesis of savings related to better care



Reward mechanisms Reward mechanisms

Improvements vs. attainment – both are used; but there is an increase in using improvement measures (at least in the USA)

Improvement works better for low and high baseline

A combination of both seems to be the best way to go

• If there are targets, how high should they be set? – even high targets have been reached (when compliance indicator) – quite a different question than for example target of vaccinated children



Reinforcing the purchaser roleReinforcing the purchaser role

In LICs new type of internal purchasers are emerging – for ex. insurances (private or public) – linked also to the user fee question

These purchaser (and pooling agents) can increase the use of (curative) health services

The use of performance incentives should be fitted in this evolution – use performance incentives for preventive services, but also for explicit quality incentives (a tool for strategic purchasing)

Epidemiological transition in LIC and MIC – using the PI schemes for shifting attention to NCD related problems the HIC evidence give some promises also for the L/MICs



References References

Campbell S., Reeves D., Kontopantelis E., Middleton E., Sibbald B., Roland M. Quality of Primary Care in England with the Introduction of Pay for Performance. N Engl J Med. 2007;357(2): 181-190

Fisher ES (2003). Medical care: is more always better? New England Journal of Medicine,349(17):1665–1667.

Gravelle, H., Sutton, M. and Ma, A. (2007), “Doctor behaviour under a pay for performance contract: evidence from the Quality and Outcomes Framework”, Centre for Health Economics

Petersen LA, Woodard LD, Urech T, et al. Does pay-for-performance improve the quality of health care? Ann Intern Med 2006; 145: 265-272.

Rosenthal M.B. Beyond pay for performance – emerging models of provider–payment reform. New England Journal of Medicine. 2008;359: 1197–200.

Rosenthal M.B., Landon B.E., Howitt K., Ryu Song H.S., Epstein A.M. Climbing Up The Pay-For-Performance Learning Curve: Where Are The Early Adopters Now? Health Affairs. 2007;26(6): 1674–1682

Performance incentive schemes in high-income countries Overview

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