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NOEL J. GENOVA, MA, PA-C, SERIES EDITOR

Paying for performance

An American PA in Britain and the NHS Quality Outcome Framework

Noel J. Genova, MA, PA-C

The author works in a private GP surgery and in a Foundation Practice serving primarily asylum seekers and refugees, both in Birmingham, West Midlands, UK, for Heart of Birmingham Teaching Primary Care Trust. She has indicated no relationships to disclose relating to the content of this article.

AAPA has published a policy paper on quality incentive programs, also known as pay-for-performance programs.¹ The Quality Care Committee has outlined necessary and preferred aspects of these programs and has advised of skills that PAs will need in the future in order to effectively participate in them.

The UK National Health Service (NHS) began a major pay-for-performance initiative in 2004, known as the Quality and Outcomes Framework (QOF).²American PAs working in the United Kingdom now have first-hand experience participating in a national quality incentive program and can pass on experiences to our colleagues. The competencies required for data collection using clinical information systems and coordinating disease management processes are somewhat different from traditional clinical competencies. This article introduces American PAs to these competencies, which may well become increasingly important for provision of health care services in the United States, and describes the QOF and its impact on primary care providers in the UK.

Pay-for-performance in British primary care

British citizens are universally insured by the NHS, which contracts with general practitioners, or GPs (the British equivalent of family physicians), for primary care services.³ Each person must register with a local GP in order to obtain all services, including specialty consultations and even some emergency services. The major source of income for GPs is their contract with NHS, which is negotiated annually by the British Medical Association (BMA) but changes significantly only at infrequent intervals.² Administration of a GP’s office (known as a surgery) is the responsibility of GP partners in the practice. This includes decisions regarding expenses such as salaries for and continuing education of ancillary personnel, telephones, costs associated with the buildings, and record-keeping systems, including computers.

Until 2004, reimbursement was based primarily upon the number of patients registered with each GP (the list). Some quality measures, such as immunization rates and rates of cervical smears and mammography, were also included in the reimbursement calculation. Growing awareness of variation in clinical practice, as well as reliable evidence-based clinical guidelines, led to agreement by 79% of voting GPs (70% turnout) to a contract that includes quality indicators.

Of great importance—and perhaps different from proposed quality incentive programs in the United States—the contract included new funds for primary care, which were approximately a 20% increase over previous funding levels. Therefore, the plan was to be able to reward all practices for achieving high quality measures, so there would not have to be “winners” and “losers.”²

The Quality and Outcomes Framework

Quality incentive programs, as defined in AAPA policy,¹ must be based on “achievement of evidence-based clinical benchmarks, patient satisfaction, and the adoption of health information technology.” Further important principles include

Focus on processes
Team approach
Voluntary participation
Use of accurate data
Feasible reporting systems
Fairness and equity, with recognition of differences in patient populations.

The NHS’s QOF meets all these criteria.

GPs may earn up to 1,050 quality points, each worth approximately £75 ($135) to the average practice with a list of 5,500 patients. Because GPs performed well in the QOF’s first year, the average three-partner practice earned more than £75,000 ($135,000) in quality bonus income.⁴ At least a portion of this money is invested back into the practice. For example, a practice may hire an extra nurse to work with patients toward improving care of their chronic conditions or update computer systems so that they can achieve better reporting of their results.

The measures themselves are in three sections—clinical care, practice organization, and patient experience. Details are publicly available on the Web.⁵

Clinical indicators are familiar to all PAs working in primary care settings and include process measures, such as obtaining a BP once a year on hypertensive patients, and outcome measures, such as recording a BP of less than 150/90 mm Hg on hypertensive patients. These are simple examples and not as hard to achieve as measures such as obtaining dilated retinal exams on 80% of all diabetic patients or maintaining glycosylated hemoglobin levels less than 7.5% on the same percentage. Points are generally awarded according to the degree of difficulty of the target.

Quality indicators of practice organization include measures of record-keeping, education, and training, accessibility for patients, and practice management.^2,5 Information about how patients experience the care they receive is obtained from surveys and patient-feedback forms.

Patients can be exempted from outcomes measures for specific, reasonable cause, such as informed dissent from recommended treatments or the presence of other serious disease conditions that make it impossible or unwise to use customary therapies. The excellent data reporting system allows accurate measures of the prevalence of the common conditions evaluated, so it is possible to estimate whether or not a practice is actually reporting information on most of the practice’s patients who have the studied conditions.

Skills and technology required for participation in QOF

Participation in any pay-for-performance program, including QOF, requires and assumes that clinicians will use sophisticated health information technology. Although data can be collected from paper medical records, this is cumbersome in practice. In Britain, 90% of GPs use computers for prescribing, and up to 50% use them for the majority of clinical care.² Depending on one’s view of electronic medical records, their necessity for pay-for-performance programs and the drive to utilize them more widely could be seen as advantages of implementing the programs.

Payment and technical support for electronic health information systems is addressed in the NHS. The skills required by frontline clinicians (in both the UK and the United States) to use those systems are well stated in AAPA’s policy paper on pay-for-performance—proficiency in their use and training in evidence-based clinical practice.¹ These skills are assumed for clinicians in the NHS, although they pose a significant challenge for some GPs.²

First-hand experience in a pay-for- performance system

Basic research training is required for proficiency and success in meeting the evidence-based quality outcomes measured in the NHS. Essentially, clinicians become collectors, cleaners, and interpreters of data. Information is not automatically obtained from the patient’s record and entered into the database from which the QOF measures are analyzed. Clinical information must be entered into templates during patient visits. Clinicians must also be able to review their outcomes and address deficiencies, which may be the result of omissions, such as neglecting to obtain laboratory tests, or to simple errors in data entry, such as not entering the results into the templates properly. The data entry process requires time and attention, either while the patient is present or at some other time.

Because quality points are assigned based on percentages of measures that reach stated targets, correct data in the denominators as well as the numerators are important. For example, if recurrent bronchitis is coded as chronic bronchitis, patients will be erroneously entered onto the chronic obstructive pulmonary disease register. Part of the clinician’s job becomes review- ing records of all patients who appear on the disease-management registers, ensuring that they belong on those registers and removing them if they do not.

The positive aspect of the system is that patients who need testing and/or treatment for their chronic diseases can be easily identified and invited in for interventions. Accurate, complete feedback on achievement of evidence-based targets is very helpful for appropriate management of chronic diseases. However, traditional clinical competencies do not suffice—someone, be it nurse, PA, doctor, or manager, must recognize errors and omissions not just in clinical care but also in data entry and analysis.

Not a panacea

Analyzing the limitations of pay-for-performance programs is beyond the scope of this article. However, it should be noted that the competencies required to perform well in a pay-for-performance system do not include many important aspects of clinical care and that most competencies are not measured at all. For example, accuracy of diagnosis, ability to communicate well with patients, proper utilization of specialty resources, and correct treatment of many to most patients fall entirely outside the pay-for-performance system. It is possible, of course, that the QOF measures serve as proxies for more complex, difficult-to-measure clinical competencies.

Conclusion

First-hand experience in Britain’s pay-for-performance program confirms the important competencies required by PAs who work in a system that uses quality incentive programs—proficiency in evidence-based medicine and skillful use of health information technology. Although many important competencies are not measured, participation in a well-designed quality incentive program assists clinicians in evaluating many aspects of the quality of their care.

Acknowledgment

Thanks to Dr. Paramjit Gill, practicing GP and Clinical Senior Lecturer in Primary Care, University of Birmingham School of Medicine, for his assistance in preparation of this manuscript.

REFERENCES

1.
McNellis R. Quality incentive programs: How AAPA policy affects you. JAAPA. 2005;18(9):18, 23-24, 28, 30-31.

2.
Roland M. Linking physicians’ pay to the quality of care—a major experiment in the United Kingdom. New Engl J Med. 2004;351(14):1448-1454.

3.
Royal College of General Practitioners. Available at: http://www.rcgp.org.uk/. Accessed May 25, 2006.

4.
Pepper D. GPs beat all predictions to score 959 QOF points. Pulse. September 10, 2005;65(35):2. Available at: http://www.pulse-i.co.uk. Accessed May 25, 2006.

5.
British Medical Association. Quality and outcomes framework guidance. Available at: http://www.bma.org.uk/ap.nsf/Content/Qualityoutcomes. Accessed May 25, 2006.