paying for quality in the uk new models n.
Skip this Video
Loading SlideShow in 5 Seconds..
Paying for Quality in the UK: New Models PowerPoint Presentation
Download Presentation
Paying for Quality in the UK: New Models

Loading in 2 Seconds...

play fullscreen
1 / 16

Paying for Quality in the UK: New Models - PowerPoint PPT Presentation

  • Uploaded on

Paying for Quality in the UK: New Models. Peter C. Smith Centre for Health Economics, University of York, UK. Four elements of the principal/agent problem. Objectives How close are those of principal and agent? Information How public, how verifiable, how costly? Incentives

I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
Download Presentation

Paying for Quality in the UK: New Models

An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.

- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
paying for quality in the uk new models

Paying for Quality in the UK: New Models

Peter C. Smith

Centre for Health Economics, University of York, UK

four elements of the principal agent problem
Four elements of the principal/agent problem
  • Objectives
    • How close are those of principal and agent?
  • Information
    • How public, how verifiable, how costly?
  • Incentives
    • Designed vs accidental
    • Numerous design issues
  • Managerial capacity
    • Designing
    • Auditing
    • Evaluating
incentives some design issues
Incentives: some design issues
  • which measures of performance to use as a basis for rewards;
  • how targets are to be set;
  • over what time period the scheme is to operate;
  • how performance measures along several dimensions are to be combined;
  • how much reward is to be dependent on attainment;
  • what is the link between improved performance and reward
  • what risk sharing arrangements are used
  • audit arrangements
  • evaluation arrangements.
incentives what are the rewards
Incentives: what are the rewards?
  • Financial (individual)
  • Financial (organizational)
  • Professional advancement
  • An easy time
  • Freedom of action
  • Prestige and perceived worth
  • Intrinsic satisfaction
general practice in england
General practice in England
  • All citizens must be registered with a general practitioner
  • Typical practice population 5,500 (but increasing)
  • Average three practitioners per practice
  • Traditional gatekeeping role in NHS
  • 2/3 general practitioners are independent contractors with the NHS
  • Traditional ‘General Medical Services’ contract developed piecemeal over decades - a mixture of capitation, salary, fee for service and grants
  • GPs are used to working in an incentivized environment
  • New GMS contract now in force.
the new gms contract
The New GMS contract
  • Developed in negotiation between government and providers
  • Approved by 79.4% in a ballot of GPs, with a response rate of 70%
  • Major emphasis on clinical quality
  • Up to 30% of income determined by quality incentives
  • Major reliance on self-reporting (with external audit).

quality and outcomes framework
Quality and Outcomes Framework
  • Each practice can earn ‘quality points’ according to reported performance
  • 146 performance indicators
  • 1,050 points distributed across indicators according to perceived importance
  • Points based on absolute level of attainment (not adjusted for local difficulty)
  • About £75 per point for an average practice, but increasing if a difficult environment
  • Minimum income guarantee (no loss of earnings)
the patient experience domain
The patient experience domain
  • Routine appointments must be not less than 10 minutes (30 points);
  • An ‘approved’ patient survey is undertaken each year (40 points);
  • The practice has ‘reflected on the results and proposed changes if appropriate’ (15 points);
  • The practice has discussed the results as a team with patient representatives, with ‘some evidence that [appropriate] changes have been enacted’ (15 points).
some arithmetic
Some arithmetic
  • For an average practice:
    • 5,500 patients;
    • 3 practitioners;
    • average levels of disadvantage.
  • £75 per point
  • So practice income at risk = £75 x 1,050 = £78,750
  • Per practitioner = £78,750/3 = £26,250 ($50,000)
  • Approximately one third of base income.
  • An intention to rise to £120 per point (a further 60%).
gms contract the strengths
GMS contract: the strengths
  • Rewarding what matters
    • structure, process and outcome
  • Balanced scorecard
  • Local freedom to decide on priorities
  • Real rewards
  • Consistent with national clinical guidelines
  • Developed by the profession
  • Rewards teams, not individuals
  • Commitment to review and update
gms contract the risks
GMS contract: the risks
  • Complexity may dilute its effectiveness
  • Unmeasured activity ignored
  • Reward structure distortive (too easy, too hard, wrong balance)
  • Discourages practice in challenging environments (cream skimming, recruitment of GPs in disadvantaged areas)
  • Discourages collaborative actions (social care)
  • Gaming (e.g. length of consultation)
  • Misrepresentation (lack of effective audit)
  • Ossification
  • Increases managerial costs
  • Undermines professional ethic, morale and unremunerated activity (‘endogenous preferences’).
gms contract why uk why now
GMS contract. Why UK? Why now?
  • Extra money required to maintain supply of GPs
  • Decision to make finance conditional on improved quality
  • Single (or dominant) payer
  • GPs with registered populations (denominator of many of the performance indicators)
  • Consensus on what constitutes ‘good’ practice (widespread national guidelines)
  • General acceptance amongst GPs of need to improve quality
  • Improving IT infrastructure (forthcoming electronic health record)
gms contract the priorities
GMS contract: the priorities?
  • Good system of audit
  • Urgent monitoring, evaluation and review
  • Addressing most grotesque anomalies
  • Better measures of quality and risk adjustment.
  • Design issues:
    • power and size of incentives
    • difficulty of targets
    • risk sharing
    • avoidance of gaming and other adverse outcomes
  • Maintaining and enhancing the support of GPs