Pay-for-performance incentives in healthcare do not reduce premature mortality rates, according to a study published in the British Medical Journal.
The Growing Burden of Non-Communicable Diseases
Around the world, governing bodies and medical insurance companies are grappling with the growing burden of non-communicable diseases (NCDs). NCDs generally fall into four categories: cardiovascular diseases, cancers, chronic respiratory illnesses, and diabetes. They are responsible for 63% of all annual deaths, and kill more than 36 million people each year, according to the World Health Organization (WHO).
NCDs are proving quite difficult to treat as their causes are related to difficult-to-change behaviors like smoking, alcohol abuse, over consumption of unhealthy foods, and physical inactivity.
Incenting Physicians May Not Improve Outcomes
In an attempt to reduce premature mortality rates, some countries have implemented pay-for-performance systems to incent physicians - with a goal of assuring high-quality healthcare with a focus on prevention.
In the UK, this pay-for-performance incentive bonus plan, called the Quality and Outcomes Framework (QOF), began in 2004. According to the official QOF website, the QOF is a voluntary, annual reward system that evaluates the quality of medical care provided by a general practitioner. QOF points are awarded according to an office’s performance in over 100 quality indicators organized into five categories:
- Management of chronic illnesses (e.g., high blood pressure, diabetes, asthma, etc.)
- Implementation of prevention measures (e.g., regular blood pressure checks)
- Offering extra services (e.g., pediatrics, maternal care)
- Quality and productivity
- Length of time spent with each patient.
Researchers from the Health eResearch Center (HeRC) at the University of Manchester analyzed data from the Office of National Statistics and the Health and Social Information Center to determine if the QOF incentives effectively reduced the rate of premature deaths in the UK.
According to HeRC’s press release, more than US $14.9 billion has been invested in the QOF program. Despite this level of investment, HeRC’s data analysis suggests that the impact of the incentives may have fallen short of previous estimates.
The HeRC team, led by Dr. Evan Kontopantelis, found that mortality rates in the UK decreased by 14% between 2007 and 2012 (i.e., between the third and eighth years of the QOF program). However, no relationship between practice performance on the clinical elements of the QOF and local mortality outcomes was found. According to Dr. Kontopantelis:
While we accept that there may be longer term benefits of the scheme [that] we cannot yet measure, it appears that the Quality and Outcomes Framework has failed to reduce mortality rates since 2007. This suggests that it has fallen far short of previous estimates of success.
Other characteristics, such as poverty or material deprivation and whether a community was urban or rural, seemed to have a greater impact on mortality rates than the quality of care provided by primary care physicians.
Although it is quite possible that there are other benefits to the population not measured directly in mortality rates, the HeRC findings suggest that the QOF indicators may need to be reconsidered. Dr. Kontopantelis states:
If this incentive scheme and others like it around the world are to continue, more attention needs to be paid to ensure that the performance indicators are more closely aligned to evidence for mortality reduction.
NCD Prevention and Treatment Prove Complex
These research findings confirm the complexity of preventing and treating NCDs, even in high-income countries. Even offering bonus incentives to physicians who meet certain standards of quality proves unrelated to – and perhaps ineffective at – meaningful reductions in mortality.
Other studies show that financial incentives may be effective at changing or improving the way physicians practice medicine, but according to this new study from HeRC, incenting physicians alone is not enough to improve outcomes when it comes to chronic illnesses.