Payments linked to clinical quality

Removing financial incentives for clinical quality can lead to a drop in performance, a study has found.

Researchers said the results of their study of financial incentives in the US has implications for the Quality and Outcomes Framework in the UK where eight clinical quality indicators are due to be removed from the scheme next year.

The researchers from Manchester University were led by Prof Helen Lester who is also clinical lead for the external group contracted by the National Institute for Health and Clinical Excellence to evaluate potential indicators for the QoF.

Prof Lester and colleagues looked at the effect of financial indicators in 35 Kaiser Permanente facilities in California, looking at quality indicators for diabetic retinopathy screening, cervical cancer screening, glycaemic control for diabetes and hypertension control between 1997 and 2007.

The results of their analysis, reported in the BMJ, found that when financial incentives were attached to diabetic retinopathy rates of screening rose from 84.9% to 88.1% but then fell by more than 7.5% to 80.5% when incentives were removed.

Rates of cervical screening also rose when financial incentives were attached and fell during the five years when they were removed, climbing once more when incentives were reattached for two years. Rates for hypertension control and glycaemic control improved when financial incentives were offered.

The research team said that if further research confirms that removal of financial incentives meant performance levels, and potentially patient care, declined there may be practical implications for policymakers, clinicians and patients.

They also emphasised that at Kaiser Permanente the incentives offered did not directly affect doctors’ income, unlike in the UK.

The researchers added: “It could be argued that attention would shift and performance

levels would decline faster within a system where personal income was attached to newly introduced indicators than removed indicators such as in the Quality and Outcomes Framework.”

However, the authors of the study said it could also be argued that slightly lower levels of achievement in one area may be more than offset by improvements in care in a different clinical area to which incentives are shifted.

The study said policymakers could consider a step-wise reduction in payments rather than a blanket removal and also consider agreeing a level in decline of performance which would trigger a review and possible reintroduction of incentives, as is the case with the Kaiser Permanente system.

Link

BMJ Article