Accounting for multimorbidity in pay for performance: A modelling study using UK Quality and Outcomes Framework data

Abstract

Background The UK Quality and Outcomes Framework (QOF) offers financial incentives to deliver high-quality care for individual diseases, but the single-disease focus takes no account of multimorbidity. Aim To examine variation in QOF payments for two indicators incentivised in ≥1 disease domain. Design and setting Modelling study using cross-sectional data from 314 general practices in Scotland. Method Maximum payments that practices could receive under existing financial incentives were calculated for blood pressure (BP) control and influenza immunisation according to the number of coexisting clinical conditions. Payments were recalculated assuming a single new indicator. Results Payment varied by condition (ϵ4.71-ϵ11.08 for one BP control and ϵ2.09-ϵ5.78 for one influenza immunisation). Practices earned more for delivering the same action in patients with multimorbidity: in patients with 2, 3, and ≥4 conditions mean payments were ϵ13.95, ϵ21.92, and ϵ29.72 for BP control, and ϵ7.48, ϵ11.21, and ϵ15.14 for influenza immunisation, respectively. Practices in deprived areas had more multiple incentivised patients. When recalculated so that each incentivised action was only paid for once, all practices received less for BP control: affluent practices received more and deprived practices received less for influenza immunisation. Conclusion For patients with single conditions, existing QOF payment methods have more than twofold variation in payment for delivering the same process. Multiple payments were common in patients with multimorbidity. A payment method is required that ensures fairness of rewards while maintaining adequate funding for practices based on actual workload.