Policy Bite: can you measure quality?


with Amanda Howe, WONCA President Elect

I was invited to a policy summit in Washington last month. Hosted by the Robert Graham Centre(1), and attended by many family medicine leads from the U.S.A., its declared purpose was to look at how changes in the payment structures for health care in the U.S.A. may, or may not, incentivise the ‘triple aim’ of first contact, coordinated, continuous, comprehensive primary care (2). The challenge was clear – the huge population of the U.S.A., still not achieving universal health coverage, and with a dazzling array of different providers and choice of health care packages. The question to me as a U.K. academic family physician was “Did pay for performance work in U.K.?” – or “Did the Quality Outcomes Framework initiative raise quality of care?” – and which aspects if any should the U.S. consider adopting? My conclusions are summarised here.

As background, U.K. family doctors (still known as GPs) are self-employed, but contracted to the National Health Service. Their clinic income from 2004 has included the opportunity to earn payments for quality of care – by systematically including clinical activities which research has identified as likely to prevent or minimise illness and its impacts. This initiative – known as the Quality Outcomes Framework - aimed to drive up overall quality of care, and to improve population health outcomes.

Did it work? Many primary care teams reached the 90% targets in the first year, suggesting that quality of care was already high. Up to 25% of income could come from such activities, but much of this was reinvested into additional staff and the costs of equipment and technology which was needed to fulfil both additional clinical and administrative commitments. Increased investment in computers for electronic records was needed to underpin patient recall, result recording, and audit reports to secure the payments. Incentivised areas showed a rise in relevant clinical activity, but non-incentivised areas did not – though they did not deteriorate either. The range of practice performance appeared to narrow, which suggests overall quality rose: but those practices with more needy populations found it harder to meet the targets, both because of greater workload and greater morbidity. Overall, the interventions chosen were more individual than population level, and did not substantially address or impact on overall health inequalities.

Family doctors were initially generally enthusiastic about being reimbursed for quality, and for improving evidence based practice. However, indicators became increasingly politically driven, and the scheme gradually lost credibility, with accusations of a ‘tick box culture’ and de-professionalisation. Concern mounted about the distorting effects on clinical practice, and pleas were made for more global indicators that might reflect overall patient care - rather than single activities such as taking a blood pressure reading. This is particularly true of the elderly and others with complex co-morbidities, where repeated appointments for different diseases risks inefficiency and fragmentation of care.

So, what did I say to colleagues in the U.S.A.? I supported payment for quality, but suggested a less complex set of indicators. I would recommend more incentives relating to community level interventions, in order to engage family doctors in population level activities (as occurs in Uruguay, where FDs get a day a week to support community and locality health initiatives). Incentives for meeting population need and support for working with more vulnerable and complex patients would also help to address health inequalities. And the model will only really work where all patients have a primary care team who will take responsibility for this proactive approach. If there are patients who do not have a regular doctor, or who are not covered for this type of care, then the quality of care will only be patchy. And that is a challenge for most health systems.

1. http://www.graham-center.org/rgc/home.html
2. Berwick DM, Nolan TW, Whittington J. The Triple Aim: Care, health, and cost. Health Affairs. 2008 May/June;27(3):759-769.