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Pay for Performance in England: Some Surprising Results

Quality-of-care measures rose faster before P4P was instituted than they did afterward.

In 2004, the U.K. introduced a pay-for-performance (P4P) program for family practices. Substantial payments are made for meeting 136 different indicators of high-quality care.

Researchers reviewed medical records in 42 representative practices for 2 years before the P4P system started (1998 and 2003) and for 2 years after it commenced (2005 and 2007). Quality scores increased annually for asthma, diabetes, and coronary heart disease during the pre-P4P evaluation period. Scores continued to rise, but more slowly, for asthma and diabetes in the post-P4P evaluation period; however, scores did not rise for coronary disease after P4P was instituted. Researchers noted no changes in patients' perception of access to care or of interpersonal aspects of care after introduction of P4P. For each of the three target diseases, after P4P commenced, some specific quality-of-care practices that were not encouraged by the incentive system actually declined. By one measure, continuity of care also declined.

Comment: To me, the most striking result of this study is that quality of care rose at a faster rate in the years before P4P than in the years afterward. The authors don't comment on what forces fueled this rise before P4P was instituted. Because this study suggests that P4P could have some pernicious effects, understanding those forces is important.

— Anthony L. Komaroff, MD

Published in Journal Watch General Medicine July 23, 2009

Citation(s):

Campbell SM et al. Effects of pay for performance on the quality of primary care in England. N Engl J Med 2009 Jul 23; 361:368.

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• Surprise Impacts of P4P
  JM Jenkins, 24 Jul 2009 9:14 AM EST
  It would be interesting to know when the shift to a P4P system was announced to the doctors, in order... [more]
• performance measures
  Sheldon S Ball, Veterans Administration, 24 Jul 2009 11:44 AM EST
  One problem with pay for performance is the performance measures themselves. Do they really measure 'performance' or 'quality of care'.... [more]
• P4P study in the UK
  D E Lighter, 24 Jul 2009 11:55 AM EST
  Translating the results of this study to the U.S. is pretty difficult, and a number of issues are extant. First,... [more]
• P4P in England
  John J. Messmer, M.D., Penn State Hershey, 24 Jul 2009 1:19 PM EST
  It seems to me that the indicators very likely improved before P4P in England because the GP's were aware of... [more]
• P4P - Punishment 4 Providers - & the Sick!
  Hans Dersch, 24 Jul 2009 4:17 PM EST
  (P4P) payments depend on meeting Quality Standards.
  
  According to this study, P4P decreases Quality of Care.
  
  Meaning worse care for... [more]
• p4p
  a.a. genut, GBMC, 24 Jul 2009 6:27 PM EST
  p4p takes time from patient care and transfers it to record keeping which we all know can be slanted. p4p... [more]
• P4P Study
  Martin W. Denker, VA Outpatient Clinic, 27 Jul 2009 8:53 AM EST
  1. The report assumes that we agree on the measures of quality of care -- they were not explained. 2.... [more]
• SURPRISE IMPACTS OF P4P
  Robert R. Brooks, The VIP Group, 17 Aug 2009 9:28 PM EST
  P4P inherently involves setting performance standards. As a management consultant, I can tell you that both research and experience show... [more]