Incentives paid to improve health care have little impact in U.K.


The world’s largest primary pay-for-performance program designed to improve patient health care and outcomes has failed to save additional lives, says a University of Michigan researcher.

An analysis of the United Kingdom’s Quality and Outcomes Framework showed modest reductions in deaths, and no statistically significant declines in mortality rates in the population targeted by the program, or for heart disease, cancer and other conditions not targeted.

For comparison, the researchers created a synthetic United Kingdom made up of 27 high-income countries that had not been exposed to pay-for-performance. They found that under QOF, the mortality rate in the U.K. improved by four or fewer people out of 100,000, depending on disease. In the “all other disease” category, the mortality rate actually increased to approximately 12 out of 100,000.

Andrew Ryan, associate professor of health management and policy at the School of Public Health, and colleagues from the U.K. say the outcome of their study could be an indicator of how similar programs elsewhere, including the United States, might fare.

The U.S. has employed a comprehensive strategy to introduce pay-for-performance programs — also known as value-based purchasing — under the Affordable Care Act since 2010.

“This program is a good proof-of-concept because it is so large,” said Ryan, who is also affiliated with the Institute for Healthcare Policy and Innovation. “It not only paid well but had quality indicators covering lots of disease areas, so our thought was if there was a program that would make improvements on population health, this was likely to be the one.”

The U.K. program, which in its first seven years paid the equivalent of $9 billion to physicians for improved performance — up to 25 percent extra — has been in place since 2004.

The researchers conducted a population-level study of mortality statistics from 1994 to 2010. It is the first study to look at mortality rates in a cross-national study comparing countries that have implemented the program with those that have not.

Previous studies, including research by Ryan, have shown that financial incentives paid to providers can lead to modest improvements in patient care, but the effects on patient outcomes have been variable, and in some cases care has suffered.   

“To us, our results raise the question, ‘What is the best way to improve population health, longevity and life expectancy?'” Ryan said.

Pay-for-performance in the U.K. is different because of the country’s system of socialized medicine, he said. For one thing, physicians are salaried so the incentives are not fee-for-service based, as they are in the U.S. 

Somewhat different versions of the QOF have been used in England, Scotland, Northern Ireland and Wales. In October, Scotland announced it no longer would participate in the program, and was looking at a different model for care.

U.K. researchers were from the University of Manchester, University of York and National Institute for Health Research.


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