Effectiveness of Quality Incentive Payments in General Practice

The study aims to evaluate the impact of an outcomes-based funding and service delivery model in Australian General Practice, comprising targeted practice incentives for enrolment with a preferred provider, longer consultations, same day access and structured follow-up after hospitalisation, on quality of care, health service utilisation and related costs for patients at increased risk of hospitalisation. The impact of the intervention will be compared to usual care, provided in the control group. If implementation of the intervention does not occur as planned at the practice level, usual care will be provided by default in the intervention group. The outcomes-based funding will be calculated and provided to intervention practices at the end of the 12 month trial. The funding components are listed below. EQUiP-GP incentive structure: The EQUiP-GP study investigates the impact of an alternate, outcomes based funding model that provides incentives linked to the quality of primary care provision by GPs. Incentive payments are paid proportional to expected health system cost savings that result from improved quality of GP care. Thus, incentives are not fixed and enable continuous quality improvement to be rewarded. Specifically, quality improvement incentive payments are made proportional to expected cost savings associated with the reduction of potentially unnecessary care (e.g. prescribing, diagnostic imaging and pathology), an increase in relational continuity for patients and the reduction of avoidable hospitalisation. These continuous incentive payments are policy relevant and health system scalable for either health system budget neutrality (payments conservatively equate to downstream cost savings) or cost savings (expected cost savings are shared between GP payments and health system). ----------------------------------------------------------------------------------------------------------------------- Enrolment minimum requirement: enrolment of older patients (>65), patients with chronic and/or complex conditions (18-65 years) and patients aged < 16 years Payment structure – study enrolment and data payments $20 per patient sign on Maximum payment: $20 per patient; $1000 for 50 patients COMMENT: Sign on $20/Pt and total for sign on and all data collection points $200/pt, $10,000 per practice Process minimum requirement: three patient encounters / year for enrolled older patients and patients with chronic and/or complex ambulatory care sensitive conditions Quality improvement incentive 1: Increased length of consultations linked to quality improvement with reduced unnecessary care for enrolled older patients and patients with chronic/ complex ambulatory care sensitive conditions Incentive structure: Payment of up to $2 per additional minute ($3 for Concession Card Holders) for consultation time in excess of an average 15 minutes across enrolled older and chronic conditions patients. Payment is up to $250 per patient ($7500 across 30 patients) on a sliding scale conditional on extent to which meet a 25% reduction in a composite measure of prescribing, diagnostic imaging and pathology ordering across this patient population in12 months of trial compared with 12 months preceding trial. Maximum payment: $250 per older and chronic patient, $7500 for 30 patients. This equates per patient to up to an additional 125 minutes (83 minutes for concession card holder) where this contributes to an average consultation time above 15 minutes across the elderly and chronic condition trial population in additional supported consultation times per patient. Scenario: A practice enrolled 10 non-concessional and 20 concession card holding older/chronic/complex patients. The average consultation time for 60 consults (6 per patient) beyond 15 minutes consultations for non-concessional patients at the end of the trial was 30 minutes. The average consultation time for 100 consults (5 per patient) for concessional card holders was 35 minutes. Across these populations the practice achieved a 20% reduction in pharmaceutical prescriptions, pathology and diagnostic imaging. The average time in excess of an average consultation time of 15 minutes was 15 minutes for non-concessional and 20 minutes for concessional patients. Hence, the maximum payments for non-concessional card holders is 6 consults x 15 min excess x $2/min =$180 or $1800 for 10 patients. This is not capped as less than $250 per patient. The maximum payment per patient for concessional card holders is 5 consults x 20 min excess x $3/min =$300 per patient. This is capped at $250 per patient and hence $5000 for 20 concession card holder patients. The total maximum payment across concession and non-concession card holders is $6800. Now as the practice achieved 80% of target 25% reduction , the practice overall receives: $6800 x 80% =$5480. -------------------------------------------------------------------------------------------------------------------------- Quality improvement incentive 2: proportion of enrolled patients <16 years seen on same day (where appropriate) exceeding 70% Process minimum requirement: 70% of enrolled patients <16 years seen on same day (where appropriate) Incentive structure: sliding scale of additional payment from $0 to maximum $30 per patient with 70% up to 100% enrolled patients <16 years seen on same day COMMENT: $30 proportional to expected cost savings from improved continuity for at risk of under-16 patients Maximum payment: $30 per enrolled patient < 16 years, $600 for 20 patients Quality improvement incentive 3: proportion enrolled chronic / complex patients (18-65 years) and patients >65 years within one week post hospital discharge exceeding 70% Process minimum requirement: 70% of enrolled patients seen <1 week post hospital discharge Performance indicator: proportion of enrolled patients seen <1 week post hospital discharge Incentive structure: sliding scale of additional payment from $0 to maximum $30 with 70% up to 100% of enrolled patients seen <1 week post hospital discharge exceeding minimum of 70% Maximum payment: $90 per enrolled patient, $2700 for 30 patients COMMENT: Only for chronic / complex patients or over 65 patients (< 16 years old should be accounted for in same day incentive) ---------------------------------------------------------------------------------------------------------------------- Quality improvement incentive 4: Potentially avoidable hospital admissions (PAH) chronic / complex patients (18-65 years) and > 65 years Performance indicator: rate of PAHs for enrolled older / chronic or complex patients in last 12 months of trial compared with 12 months preceding trial (after adjustment for age, sex, and socioeconomic status measured by Index of Relative Socioeconomic Disadvantage) Incentive structure: sliding scale of additional payment from $0 to maximum $200 with 0 to 40+% reduction in PAH rate in last 12 months of trial compared with 12 months preceding trial (after adjustment for age, sex and socioeconomic status measured by Index of Relative Socioeconomic Disadvantage) Maximum Payment: $200 per enrolled patient with 40% reduction achieved; $6000 for 30 patients _______________________________________________________________________________ Quality improvement incentive 5: Potentially avoidable hospital admissions < 16 yo Performance indicator: rate of PAHs for < 16 yos in last 12 months of trial compared with 12 months preceding trial (after adjustment for age, sex and socioeconomic status measured by Index of Relative Socioeconomic Disadvantage) Incentive structure: sliding scale of additional payment from $0 to maximum $60 with 0 to 40+% reduction in PAH rate in last 12 months of trial compared with 12 months preceding trial (after adjustment for age, sex and socioeconomic status measured by Index of Relative Socioeconomic Disadvantage) Maximum Payment: $60 per enrolled patient with 40% reduction achieved; $1200 for 30 patients COMMENT: Max $150 with 100% reduction modified to maximum $60 with 40% reduction Each intervention practice will be facilitated in the uptake of the intervention by 3 x 2 hour sessions with a trial facilitator, conducted at two monthly intervals at the intervention practices over the first 6 months of the trial. These sessions will include: 1. Training in the trial procedures 2. Discussion of potential alterations to practice procedures to facilitate the trial procedures 3. Access to educational and quality improvement resources to inform practice changes Trial facilitators will monitor adherence to the intervention as they will observe, discuss, troubleshoot and report on trial progress at each site. Adherence to trial procedures is also monitored by quarterly in-practice data audits.