Transcript Slide 1
Financing of first-line care in England
Matt Sutton Professor of Health Economics University of Manchester, UK [email protected]
VVAA Utrecht 28 March2012
Outline
• Reforms of payment systems for primary care • Reforms of payment systems for secondary care • Reforms of budget-holding for secondary care
Financing and structure of the NHS in England
• The National Health Service is financed from general taxation – patients incur (almost) no charges for NHS medical care • Patients register with general practices, who: – are independent contractors organised in partnerships – receive weighted capitation to provide primary care ‘in-hours’ – act as ‘gatekeepers’ for hospital care • Hospital Trusts are paid by activity by local health authorities for: – referrals seen and treated – patients attending Accident and Emergency Departments
Current financing and organisation issues
• General practices have little incentive to service patient demands • Hospital Trusts have strong incentives to service patient demands • Existing local health authorities (Primary Care Trusts) have: – no control over revenue – little control over contractual terms with providers – little control over expenditure
PAYMENT SYSTEMS FOR PRIMARY CARE
Pay-for-performance for UK primary care providers
• • • • • • UK government decided to increase health funding substantially in 2000 New contract for primary medical care developed during a 18-month negotiation between government and union, with clinical academic experts GP vote in June 2003; 70% turnout; 79% voted in favour Major reliance on self-reporting with external audit This emphasis on clinical quality complemented a range of ongoing quality improvement initiatives Intended to link ~20% of income to performance incentives
New contract for primary care providers
• Previous GP contract developed piece-by-piece over decades – a mixture of capitation, allowances/salary, partial cost reimbursement, fee-for-service and target payments • New contract since 2004 is with practices not individual GPs • Payments comprise: – A Global Sum for
Essential Services
(weighted capitation) –
Seniority Allowances
(based on length of service) – –
Additional Services
payments (opt-outs)
Enhanced Services
payments (opt-ins) –
Quality and Outcomes Framework
(P4P)
QOF domains - 2011/12
• • • • Clinical domain – Process indicators for ~20 health conditions Organisational domain – Records and information – Information for patients – Education and training – Practice management – Medicines management – Quality and productivity Patient experience domain – Length of consultations Additional services domain – Cervical screening, child health, maternity, contraception
Hypertension indicators
Controlled blood pressure for hypertensive patients Points earned Between the thresholds, revenue increases linearly with the proportion treated
57 38 40 (60-40)/(70-40) x 57 = 38 60% 70
Achievement %
100
QOF achievement in England
Year Points available Average points achieved Proportion of practices at maximum points Proportion of practices achieving <90% of points 2004/5 1,050 91% 2005/6 1,050 96% 2006/7 1,000 96% 2007/8 1,000 97% 2008/9 1,000 2009/10 1,000 95% 94% 3% 10% 5% 8% 2% 1% 12% 7% 8% 15%
GP pay levels
£300,000 Gross Earnings • QOF bill is £1bn per year ~ £16 per capita ~1% of NHS budget • Average practice gets £130k • NHS spent 9.4% more than expected in first 3 years • QOF increased GP pay by 38% in 2 years £250,000 £200,000 £150,000 £100,000 £50,000 Expenses Income Before Tax £0 2002/03 2003/04 2004/05 2005/06 2006/07 2007/08 2008/09
Source: Doran et al (BMJ, 2011)
Raising the thresholds for immunisation against flu
Year Condition CHD COPD Diabetes Points 7 6 3 2004/5-2005/6 Lower threshold Upper threshold 2006/7-2009/10 Lower threshold Upper threshold 25% 85% 40% 90% 25% 25% 85% 85% 40% 40% 85% 85% Stroke 2 25% 85% 40% 85% • The 5% increase in the upper payment threshold led to: • 0.41% increase in the proportion of patients immunised • 0.26% increase in the proportion of patients declared ineligible Source: Kontopantelis et al (HSR, 2011)
Effect on emergency hospital admissions
0,5 0,4 0,3 0,2 0,1 0 -0,1 -0,2 2000/1 2001/2 2002/3 Incentivised ACSC 2003/4 2004/5 Non-ACSC 2005/6 2006/7 2007/8 2008/9 Non-Incentivised ACSC Source: Harrison et al, in progress
Summary of the evidence on the QOF
• • • • • High expenditure commitment – In general, the targets seem to have been set at too low a level – The payments on offer appear to have been excessive Quality was already improving Impact results are sensitive to the choice of counterfactual – Performance increased most on incentivised indicators – Explicitly targeted patients also experienced positive spillovers – Mixed evidence on effects on quality for untargeted patients – Emerging evidence of impact on use of hospital care Evidence of ‘gaming’ by some practices to achieve improved scores Performance shows some sensitivity to design properties of the incentives, including payment levels and upper thresholds
PAYMENT SYSTEMS FOR SECONDARY CARE
Changes in hospital financing
2004/5 Activity-Based Financing 2010/11 Commissioning for Quality and Innovation Best Practice Tariffs Marginal emergency tariff Non-payment policies
Marginal and non-payment policies
•
2010/11
Marginal payment (30%) for emergency admissions above level of the previous year • •
2011/12
Non-payment for emergency readmission (<30 days) after elective admission – With exclusion of children, cancer care, traffic accidents etc. Non-payment for emergency re-admission (<30 days) after emergency admission above a locally-agreed threshold rate •
2012/13
Local reviews of emergency re-admissions avoided and by whom?
– what proportion could have been
BUDGET-HOLDING FOR SECONDARY CARE
Previous experience with budget-holding by GPs
• Throughout the 1990s, practices could opt to become ‘
Fundholders
’ • Fundholders held ‘soft’ budgets for prescribing and referrals, negotiated contracts with hospitals and re-invested savings • Estimated to have reduced elective referrals by 4-5% • Abolished in 1999 because represented a ‘two-tier’ service • From 2005, local health authorities were instructed to involve practices more through
Practice-Based Commissioning
• Progress and organisation was highly variable across the country
New Clinical Commissioning Groups
• Groups of local general practices (approx. 250 Groups) • ‘Membership’ organisations • Will hold ‘hard’ budgets for prescribing, community and non specialist hospital care • Covers elective and emergency hospital care • Can re-invest ‘savings’ and receive a ‘Quality Premium’ bonus • Budgets will be set using a weighted capitation formula • Total budget of approximately £80bn
Contract
Current organisation
Department of Health Allocation Primary Care Trusts Contract Payment claims General practices Appointments Referrals Patients Hospital Trusts A&E attendances
Planned re-organisation
Department of Health NHS Commissioning Board Allocation Contract Clinical Commissioning Groups Contract General practices Referrals Appointments Patients Payment claims Hospital Trusts A&E attendances
Types of ‘incentives’ that purchasers might face
• Intrinsic motivation • Reputational risks, through public reporting – Career concerns – Competition for members • Earned autonomy • Financial incentives
CONCLUDING REMARKS
Potential uses of financial mechanisms
• Financial incentives could be used to – Stimulate more activity in primary care – Reduce activity in secondary care • Local budget-holding may – Shift activity into the community, hopefully at same or better quality – Reduce elective care, hopefully unnecessary care – Prevent emergency care, hopefully inappropriate care
Some lessons from the QOF experience
• • • • • • Involve health care professionals in the content of an incentive scheme Establish a quantitative ‘baseline’ against which impact can be measured Recognise the uncertainty over the economic aspects of incentives Avoid incentives to ‘game’, double-payments and redundant payments Leave enough time to evaluate the scheme carefully – Measured domains – Unmeasured domains – Costs and outcomes Agree with providers that any innovative funding scheme will be continuously monitored, reviewed and amended