Re: Why pay for performance may be incompatible with quality improvement
It was like a breath of fresh air reading the BMJ editorial cited above. I have for some eight years now viewed some of the 'quality' recommendations in the 2004 G.P. Contract with caution. For one thing the word 'quality' appears akin to a newly discovered term not known of hereto! For another, its implications appear to be implicitly related to volume output and related income generation. Where for a designated disease category, a Practice has smaller numbers that do not match the national/local prevalence figures it is viewed with suspicion irrespective of the fact that the Practice has closely researched it. Also, the funding mechanism is geared towards 'illness' and, therefore, consequential treatment. The more 'ill' patients' you have the more the opportunity to meet the criteria for 'treatment' and generate QOF points that equate to money. By contrast, the healthy patient who does not fit into a categorized illness category is merely worth the per capita fee. The system is further bedevilled by the fact that lowering of some diagnostic threshold enlarges the numbers of potentially 'ill' patients in the category. It is not surprising, then, that it pays to have larger numbers of 'ill patients' on one's list and to be rewarded for treatment that yields the highest figures for the maximum payment in the categorized illness category.
Although it is common knowledge that most people are reluctant to label themselves as ill, the reverse would apply to those who stand to gain financially if the volume pool of "illness" was enlarged. This is what must have prompted one Maryland rehabilitation hospital to have diagnosed 287 cases of "kwashiorkor" on the basis of "protein malnutrition " alone.
I find it greatly perturbing that if the threshold diagnosis for some illnesses continues to be lowered it would only be a matter of time before every single individual could be labelled 'ill' and requiring 'treatment'. Also, to meet the highest level of payment in a categorized QOF illness category, and where the laboratory figures are not in the 'desirable range' most practitioners respond by increasing the strength and dose of prescribed medications. 'Quality' is,then, perceived to have been attained on the basis of laboratory figures alone. I wonder how many prescribing practitioners have ever considered the detrimental impacts on the long-term health of their patients which is magnified in those on polypharmacy. This is one event yet awaiting to unfold.
One does not have to look far to see why the national drug budget is becoming unsustainable. Rather than examine the relevancy or otherwise of so many receiving treatment, the trend has been to switch to generics and/or reduce the frequency of drug administration to a once daily dose in an attempt to contain costs. Clearly, this is no more than scratching the surface.
The oddity of some of the reward criteria in the 2004 Contract is also striking. It appears that the emphasis is on rewarding those who are viewed as 'bad Practices'. What logic is it that reasons that if you have no patient complaints in the Practice, then, you receive neither recognition nor payment! Or that, if no 'significant events' have occurred in the Practice, then no reward payments are forthcoming. Could it be that only those viewed as 'bad doctors' need encouragement by way of financial reward. How could the point have been missed that 'good doctors' also need to be rewrded to continue to be 'good' or even better doctors. After all, that is surely perceived as the desirable end point!
Or, is the distorted logic consistent with the prevailing view that you get more funding if you overspend and are penalised by having your funding cut if you are efficient enough to make a saving on your budget!
The Cochrane Review's finding on the treatment of mild hypertension is an eye-opener and this may not be the only area of illness category that might prompt a rethink. Straight-line thinking has encouraged the lowering of B.P. to 'desirable' set limits. A phenomenal slice of the national drugs budget is devoted to this activity and financial inducement provided to meet the banding levels. Likewise, the drive to lower blood lipid levels is relentlessly applied and no lower limit seems to be low enough. This is,again, consuming a significant slice of the national drugs budget and needs a discriminatory critical review in terms of value for money.
Some may remember the false economy in the issue of free spirometers to general practitioners so that they could do the procedure themselves on their COPD population thereby obviating the need of the employed technicians. What was not perceived was that the quality of data was dependent on the aptitude and experience of the operator; the device alone could not deliver the goods!
Time has passed and we have lived but have we learned?.
Rapid Response:
Re: Why pay for performance may be incompatible with quality improvement
It was like a breath of fresh air reading the BMJ editorial cited above. I have for some eight years now viewed some of the 'quality' recommendations in the 2004 G.P. Contract with caution. For one thing the word 'quality' appears akin to a newly discovered term not known of hereto! For another, its implications appear to be implicitly related to volume output and related income generation. Where for a designated disease category, a Practice has smaller numbers that do not match the national/local prevalence figures it is viewed with suspicion irrespective of the fact that the Practice has closely researched it. Also, the funding mechanism is geared towards 'illness' and, therefore, consequential treatment. The more 'ill' patients' you have the more the opportunity to meet the criteria for 'treatment' and generate QOF points that equate to money. By contrast, the healthy patient who does not fit into a categorized illness category is merely worth the per capita fee. The system is further bedevilled by the fact that lowering of some diagnostic threshold enlarges the numbers of potentially 'ill' patients in the category. It is not surprising, then, that it pays to have larger numbers of 'ill patients' on one's list and to be rewarded for treatment that yields the highest figures for the maximum payment in the categorized illness category.
Although it is common knowledge that most people are reluctant to label themselves as ill, the reverse would apply to those who stand to gain financially if the volume pool of "illness" was enlarged. This is what must have prompted one Maryland rehabilitation hospital to have diagnosed 287 cases of "kwashiorkor" on the basis of "protein malnutrition " alone.
I find it greatly perturbing that if the threshold diagnosis for some illnesses continues to be lowered it would only be a matter of time before every single individual could be labelled 'ill' and requiring 'treatment'. Also, to meet the highest level of payment in a categorized QOF illness category, and where the laboratory figures are not in the 'desirable range' most practitioners respond by increasing the strength and dose of prescribed medications. 'Quality' is,then, perceived to have been attained on the basis of laboratory figures alone. I wonder how many prescribing practitioners have ever considered the detrimental impacts on the long-term health of their patients which is magnified in those on polypharmacy. This is one event yet awaiting to unfold.
One does not have to look far to see why the national drug budget is becoming unsustainable. Rather than examine the relevancy or otherwise of so many receiving treatment, the trend has been to switch to generics and/or reduce the frequency of drug administration to a once daily dose in an attempt to contain costs. Clearly, this is no more than scratching the surface.
The oddity of some of the reward criteria in the 2004 Contract is also striking. It appears that the emphasis is on rewarding those who are viewed as 'bad Practices'. What logic is it that reasons that if you have no patient complaints in the Practice, then, you receive neither recognition nor payment! Or that, if no 'significant events' have occurred in the Practice, then no reward payments are forthcoming. Could it be that only those viewed as 'bad doctors' need encouragement by way of financial reward. How could the point have been missed that 'good doctors' also need to be rewrded to continue to be 'good' or even better doctors. After all, that is surely perceived as the desirable end point!
Or, is the distorted logic consistent with the prevailing view that you get more funding if you overspend and are penalised by having your funding cut if you are efficient enough to make a saving on your budget!
The Cochrane Review's finding on the treatment of mild hypertension is an eye-opener and this may not be the only area of illness category that might prompt a rethink. Straight-line thinking has encouraged the lowering of B.P. to 'desirable' set limits. A phenomenal slice of the national drugs budget is devoted to this activity and financial inducement provided to meet the banding levels. Likewise, the drive to lower blood lipid levels is relentlessly applied and no lower limit seems to be low enough. This is,again, consuming a significant slice of the national drugs budget and needs a discriminatory critical review in terms of value for money.
Some may remember the false economy in the issue of free spirometers to general practitioners so that they could do the procedure themselves on their COPD population thereby obviating the need of the employed technicians. What was not perceived was that the quality of data was dependent on the aptitude and experience of the operator; the device alone could not deliver the goods!
Time has passed and we have lived but have we learned?.
Competing interests: No competing interests