Performance incentive schemes in high-income countries Overview

1. Performance incentives in the high income countries – key issues and lessons learned (for the low-income countries) Riku ElovainioWorld Health Organization, GenevaINCENTIVE SCHEMES AND PERFORMANCE OFHEALTH CARE PROVIDERS IN LICS …Clermont-Ferrand – 17 Dec 2009 (Session 5)

2. Performance incentive schemes in high-income countries Overview

3. 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

4. Performance Incentives in high-income countries – the basics • 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)

5. 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)

6. Elsewhere? • 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.

7. 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

8. Who are targeted? • Individual physicians (CAPI) • Primary Care practices, physician networks (QOF, PIP) • Hospitals (PHQID, IHA, etc.)

9. Focus 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)

10. 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

11. Has it worked? Some positive results … CMS PHQID UK QOF Source: Campbell et al. 2007 … Petersen et al. 2006 : 12 /15 evaluation studies reported positive results … … 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)

12. 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

13. Some lessons learned

14. 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

15. 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

16. 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

17. Cost scenarios Cost increase Cost neutral "New money"; Ex. QOF Reallocation between interventions or providers Return on investment

18. Bonus optimization – return on investment • Optimal reward = $175 /patient/Y • Physician bonus= $4300 • 1.5 $million net benefit Using P4P to improve diabetes care Based on the hypothesis of savings related to better care Bridges to Excellence 2003-208, Five Years on : Bridges Built, Bridges to Build

19. 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

20. Reinforcing 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

21. 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