"Mind the gap!" Evaluation of the performance gap attributable to exception reporting and target thresholds in the new GMS contract: National database analysis.
BACKGROUND
The 2003 revision of the UK GMS contract rewards general practices for performance against clinical quality indicators. Practices can exempt patients from treatment, and can receive maximum payment for less than full coverage of eligible patients. This paper aims to estimate the gap between the percentage of maximum incentive gained and the percentage of patients receiving indicated care (the pay-performance gap), and to estimate how much of the gap is attributable respectively to thresholds and to exception reporting.


METHODS
Analysis of Quality Outcomes Framework data in the National Primary Care Database and exception reporting data from the Information Centre from 8407 practices in England in 2005 - 6. The main outcome measures were the gap between the percentage of maximum incentive gained and the percentage of patients receiving indicated care at the practice level, both for individual indicators and a combined composite score. An additional outcome was the percentage of that gap attributable respectively to exception reporting and maximum threshold targets set at less than 100%.


RESULTS
The mean pay-performance gap for the 65 aggregated clinical indicators was 13.3% (range 2.9% to 48%). 52% of this gap (6.9% of eligible patients) is attributable to thresholds being set at less than 100%, and 48% to patients being exception reported. The gap was greater than 25% in 9 indicators: beta blockers and cholesterol control in heart disease; cholesterol control in stroke; influenza immunization in asthma; blood pressure, sugar and cholesterol control in diabetes; seizures in epilepsy and treatment of hypertension.


CONCLUSIONS
Threshold targets and exception reporting introduce an incentive ceiling, which substantially reduces the percentage of eligible patients that UK practices need to treat in order to receive maximum incentive payments for delivering that care. There are good clinical reasons for exception reporting, but after unsuitable patients have been exempted from treatment, there is no reason why all maximum thresholds should not be 100%, whilst retaining the current lower thresholds to provide incentives for lower performing practices.
Primary Care Group, School of Medicine Health Policy and Practice, University of East Anglia Norwich, UK. r.fleetcroft@uea.ac.uk
Robert
R
Fleetcroft
Nicholas
N
Steel
Richard
R
Cookson
Amanda
A
Howe
D003284:Contract Services / Q000458:organization & administration*; D005194:Family Practice / Q000191:economics / Q000592:standards*; D006302:Health Services Research; D006801:Humans; D010816:Physician Incentive Plans; D011785:Quality Assurance, Health Care / Q000191:economics; D019984:Quality Indicators, Health Care; D012052:Reimbursement, Incentive; D012456:Salaries and Fringe Benefits; D012959:Socioeconomic Factors; D013222:State Medicine / Q000191:economics*; D006113:United Kingdom