The Unintended Consequences of f l l hPaying for Quality in Health Care

Tim Doran

University of ManchesterHarvard School of Public Health

DoranNPCRDC Paying Physicians for Quality

Nuffield Health Strategy Summit, 3 March 2011

• Adverse effect on professionalism and motivation 

• Neglect of non‐incentivized activities

• Widening of health inequalities

Case Study One: Q lit d O t F kQuality and Outcomes Framework 

DoranNPCRDC Paying Physicians for Quality

Influenza immunisation

The Quality and Outcomes FrameworkResults

Paying for qualityThe United Kingdom

The United States

100

Influenza immunisationIncentivized (CHD) and unincentivized (CKD)

90

95

100

75

80

85

Incentivizedment rate

65

70

Incentivized

Unincentivized

Achievem

50

55

60

2000/1 2001/2 2002/3 2003/4 2004/5 2005/6 2006/7

NPCRDC Paying Physicians for Quality 

Uplift in achievement

Paying for qualityThe United Kingdom

The United States

The Quality and Outcomes FrameworkResults

Uplift in achievementActual versus expected achievement: Year 1 (2004/5) and Year 3 (2006/7)

25

35

25

35 27= 1 0

15= 7 6

1515

ent a

bove 

ed ra

te

4= 11

2= 7

5

5

5

5

Achieveme

pred

icte = 11

5= 7 11

‐15

‐5

‐15

‐5

Year 1 Year 3

NPCRDC Paying Physicians for Quality 

Year 1 Year 3

Adventures in Health Care ReformAdventures in Health Care Reform 

DoranNPCRDC Paying Physicians for Quality

Potomac feverPotomac fever

DoranNPCRDC US Health Care Reform

Reforme oPast attempts

“Democrats want to create a Democrats want to create a government-run system for not providing health care while providing health care, while Republicans say coverage is best denied by allowing private insurers to denied by allowing private insurers to make it unaffordable for as many citizens as possible ”

NPCRDC US Health Care Reform

citizens as possible.