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Observational Study
. 2018 Dec;68(677):e811-e818.
doi: 10.3399/bjgp18X699797. Epub 2018 Nov 5.

Influence of financial and reputational incentives on primary care performance: a longitudinal study

Thomas Allen  1 , William Whittaker  1 , Evangelos Kontopantelis  2 , Matt Sutton  2
Affiliations
Observational Study

Influence of financial and reputational incentives on primary care performance: a longitudinal study

Thomas Allen et al. Br J Gen Pract. 2018 Dec.

Abstract

Background: The Quality and Outcomes Framework has generated reputational as well as financial rewards for general practices because the number of quality points a practice receives is publicly reported. These rewards vary across diseases and practices, and over time.

Aim: To determine the relative effects on performance of the financial and reputational rewards resulting from a pay-for-performance programme.

Design and setting: Observational study of the published performance on 42 indicators of 8929 practices in England between 2004 and 2013.

Method: The authors calculated the revenue offered (financial reward, measured in £100s) and the points offered (reputational reward) per additional patient treated for each indicator for each practice in each year. Fixed-effects multivariable regression models were used to estimate whether the percentage of eligible patients treated responded to changes in these financial and reputational rewards.

Results: Both the offered financial rewards and reputational rewards had small but statistically significant associations with practice performance. The effect of the financial reward on performance decreased from 0.797 percentage points per £100 (95% confidence interval [CI] = 0.614 to 0.979) in 2004, to 0.092 (95% CI = 0.045 to 0.138) in 2013. The effect of the reputational reward increased from -0.121 percentage points per quality point (95% CI = -0.220 to -0.022) in 2004, to 0.209 (95% CI = 0.147 to 0.271) in 2013.

Conclusion: In the short term, general practices were more sensitive to revenue than reputational rewards. In the long term, general practices appeared to divert their focus towards the reputational reward, once benchmarks of performance became established.

Keywords: financial incentives; general practice; longitudinal study; pay-for-performance; reputational incentives.

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Figures

Figure 1.
Figure 1.
Variations across indicators and over time in the financial and reputational rewards offered per patient treated for two indicators. Diabetes indicator: patients with a diagnosis of proteinuria or microalbuminuria who are treated with angiotensinconverting enzyme inhibitors. Mental health indicator: patients on lithium therapy with a record of lithium levels.
Figure 2.
Figure 2.
Variations across practices and over time in the financial and reputational rewards offered per patient treated for two practices.
Figure 3.
Figure 3.
Estimated impact on percentage of patients treated (with 95% confidence intervals) associated with one-unit changes in financial and reputational rewards offered by year. Y-axis measures the size of the coefficient on the respective reward. Each reward was interacted with a categorical year variable to allow the effect to differ in each of the 9 years observed. Regression included control variables for year, registered population of the practice, physicians per 1000 registered patient, and local area deprivation.
See this image and copyright information in PMC

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