Pay for Performance – NHHRC Wants It – Can it Get There and is it a Good Idea?

It seems the National Health and Hospitals Reform Commission (NHHRC) is giving serious consideration to an implementation of so called “Pay for Performance”. This is the idea where a part of a clinicians income is related to undertaking specific clinical activities that are seen as valuable and useful – e.g. various screening actions, vaccination and disease specific clinical monitoring and treatment.

The idea is discussed here:

Performance pay likely for doctors

Adam Cresswell, Health editor | May 06, 2009

Article from: The Australian

LINKING the pay of doctors and nurses to measures of how well they treat their patients, or how quickly they are seen, is likely to emerge as a key plank of the federal Government's health reform push.

The National Health and Hospitals Reform Commission, which is due to deliver its final report by June 30, says the current "fee for service" system of Medicare rebates does little to encourage the most effective treatments, because doctors get paid for each clinical consultation or activity, regardless of whether the patient recovers well or not.

It is likely to recommend other ways of paying medical and allied health staff, such as providing funds for bundles of care.

The NHHRC's chairwoman, Christine Bennett, gave an example of paying for a course of treatments spanning days or weeks for patients with conditions such as type 2 diabetes.

"We have to go beyond that (activity-based payments) to say are we getting the right activity, and are we getting good outcomes for that activity?" she said.

Pay for performance is a controversial issue in the medical profession. Some doctors fear such systems constrain their freedom to choose the best treatment for individual patients. Some GPs have expressed concerns that unscrupulous doctors might seek to maximise their income from new incentives by cherry-picking affected patients and neglecting others. Dr Bennett said allowing certain categories of patients, such as parents of young children and people with chronic and complex needs, to enrol with general practices on a voluntary basis might allow new types of financial support. This might allow the practice to hire additional staff -- an exercise physiologist, podiatrist, cardiac rehabilitation nurse -- depending on the needs of the individual practice's patients.

More here:

http://www.theaustralian.news.com.au/story/0,25197,25436108-23289,00.html

As can be imagined there are a variety of views on the idea.

Doctors split over performance pay

Adam Cresswell, Health editor | May 07, 2009

Article from: The Australian

PLANS by the federal Government's main health reform body to push for a new system of paying health workers for good performance has won backing from some doctors, despite opposition from the profession's peak body.

A number of GPs yesterday spoke out in support of plans by the National Health and Hospitals Reform Commission to pursue new payment systems in preference to the fee-for-service Medicare system, under which doctors are paid irrespective of whether the treatment provided was appropriate or successful.

Inner-west Sydney GP Lydia Kovach said Medicare made doctors into "piece workers" and created incentives to churn patients through the consulting room quickly, rather than work out what was causing complex health problems.

"Anything that moves away from fee for service ... has to be a good idea, because then you are able to look at the patient and not the time," Dr Kovach said.

"Medicare doesn't reward quality so much as quantity."

Yesterday, The Australian reported that the commission planned to pursue and flesh out, in its final report due in June, a previously flagged intention to recommend a shifting scale of payments for doctors, nurses and other health workers based on performance. Commission chairman Christine Bennett said this might be done by various means, such as measuring the proportion of patients with chronic conditions who were given a seasonal flu vaccination, whether patients with heart disease were prescribed beta-blockers or other treatments considered best practice, or how long patients had to wait before receiving treatment.

More here:

http://www.theaustralian.news.com.au/story/0,25197,25440875-23289,00.html

For those who can access Australian Doctor the following long and detailed article is invaluable:

Target practice

28-Apr-2009

Pay-for-performance may be on the cards for Australian GPs. We ask doctors with experience of the UK system: does it improve care or distort clinical priorities? By Heather Ferguson

ON paper, it sounds great: pay GPs a bonus when their patients achieve certain health targets, such as lower hypertension or blood sugar. In theory, everyone wins. Patients are healthier and GPs are better rewarded for their efforts.

That certainly seems to be the view of the National Health and Hospitals Reform Commission (NHHRC). Earlier this year, in its interim report to the Federal Government, the commission recommended that GPs be rewarded for meeting specific targets of disease prevention, chronic illness and avoidable complications.

In another report released last year, the commission had proposed targets around asthma, diabetes management and antibiotic prescribing for URTIs.

For Australian GPs who have worked in the UK recently, it’s all sounding very familiar. Since April 2004 Britain’s GPs have been able to earn bonuses via the Quality and Outcomes Framework (QOF), a list of 76 targets in areas such as coronary heart disease, diabetes, cancer, mental health, and practice organisation.

Each target hit earns a certain number of points: the more points a practice achieves, the more it earns. And the money on offer is staggering. Practices can earn a maximum of about 1000 points each year. That meant that in 2005-06, the average four-GP practice stood to gain up to £130,000 ($A267,000) a year if it met all the targets. In that year, practices collectively raked in an additional one billion pounds in QOF payments.

A wonderful idea, you might think. But it’s all led to some “weird behaviour” says Australian GP Professor Richard Hays, the head of the school of medicine at Keele University in the UK.

For example, practices that want to meet one particular target need to ensure patients can make an appointment within 48 hours. But some practices have simply made it a policy not to make appointments more than 48 hours in advance. The result is a mad scramble by patients each day to try and get an appointment.

.....

WINNERS AND LOSERS

The percentage of heart disease patients with controlled blood pressure jumped from 48% in 1998 to 82% in 2005. The number of patients with controlled cholesterol also leaped, from 17% to 73%.

Pap smear and vaccination rates in deprived areas have moved closer to those in affluent areas.

GPs in deprived areas have done surprisingly well in meeting targets but practices serving deprived populations are unfairly penalised for high morbidity rates.

The QOF cost Britain £3 billion between 2004-07.

To work, QOF needs to be backed by audits, electronic health records and national guidelines.

Some GPs have “gamed” the system to meet targets. For example, a few practices may have “re-coded” patients with heart disease.

Source: National Primary Care Research and Development Centre paper, November 2007

Much more here (subscription required).

http://www.australiandoctor.com.au/articles/8e/0c06018e.asp

The following is also very useful.

Proper incentives key to P4P success: study

By Rebecca Vesely

Posted: May 7, 2009 - 12:00 pm EDT

Pay-for-performance can be effective if physicians get the right incentives, according to a study by Bridges to Excellence published in the American Journal of Managed Care.

The report used statistical data from Bridges to Excellence pay-for-performance programs with more than 13,500 participating physicians in four cities: Albany, N.Y.; Boston; Cincinnati; and Louisville, Ky. The two programs focused on improving patient care while reducing medical errors in medical practices, and improving care for diabetes patients.

More here:

http://www.modernhealthcare.com/apps/pbcs.dll/article?AID=/20090507/REG/305079966/-1

The full paper is here:

http://www.ajmc.com/media/pdf/AJMC_09May_deBrantes305to310.pdf

The most important things to consider are first does pay for performance work and if it does what is needed for it to be implemented.

It seems the answer to the first question is that well designed and carefully and responsively evaluated programs can influence clinical behaviour. If the incentive goals are developed with an eye to avoidance of all the possible ‘perverse incentives’, and the scale of the incentives is reasonable it is possible to get net improvements in population care and outcomes.

As far as the second question is concerned there is substantial non-obvious complexity that needs to be addressed.

First clinicians and clinical teams have to be well organised and be able to deliver the full spectrum of care for the individual patient over time while both staying in touch with the patient and tracking clinical outcome.

This really means that a ‘medical home’, patient registration or similar arrangement is needed.

Secondly there is a major information management and co-ordination task. This is because any pay for performance program needs to have clear outcome objectives which are not only fully tracked but are also encouraged via point of care decision support that understands the patient context (i.e. diagnoses, current problems, treatments etc). This can only be achieved using quite advanced clinical systems to support the caring clinicians and these systems need to be capable of appropriate coding of the clinical situation so relevant targets and guidelines are provided at the point of care.

Nothing in the NHHRC work to date suggests they understand this or do they seem to realise that without this key information infrastructure any pay for performance program simply won’t work in my view.

Let me be quite clear here. An advanced e-health infrastructure is not important if the pay for performance approach is to be adopted it is mandatory and it cannot work without it. It also cannot be put in place overnight – or even over a year or two. Minister Roxon and the NHHRC need to take careful note!

There is little doubt that quality and safe clinical practice addresses both errors of omission and commission in care delivery, and that if based on appropriate evidence, the use of techniques to obtain clinical consistency can make a positive difference of overall outcomes. What is harder is to ensure the human and technical factors that assist clinicians get care right as often as possible are carefully thought through and sensibly implemented. Pay for performance is a possible part of a holistic approach to reaching that goal.

David.