Effectiveness of Quality Incentive Payments in General Practice

INTERVENTION: 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. 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. Now as the practice achieved 80% of target 25% reduction , the practice overall receives: $6800 x 80% =$5480. ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ CONDITION: Quality of general practitioner care PRIMARY OUTCOME: Change in the mean score of the Primary Care Assessment Tool continuity scale. Hospitalisation rates as assessed by linked hospital data. 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. 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. SECONDARY OUTCOME: Pathology test rates assessed by EHR data. Cost‐effectiveness assessed by joint cost and effect distributions on the cost‐effectiveness plane (two strategy comparisons), cost‐disutility plane (multiple strategy comparisons) and relevant summary measures. Summary measures are determined by aims of the health economic analysis which are to calculate: ; ‐ Net benefit and cost‐effectiveness acceptability curves for the two strategy comparison ; ‐ Expected net loss curves and frontiers for multiple strategy comparisons ; ‐ Expected net loss panes and surfaces and multiple domain of effect comparisons. Health related quality of life assessed by EQ‐5D‐5L questionnaire. Hospital presentations as assessed by linked hospital data. Hospital presentations as assessed by patient report. Hospitalisation rates as measured by EHR Medical imaging rates assessed by EHR data. Medical Imaging rates assessed by linked Medicare data. Mortality assessed by linked Deaths registry data. Number of consultations assessed by EHR data. Number of medications in medication list assessed by EHR data. Number of total prescriptions assessed by EHR data. Pathology test rates assessed by linked Medicare data. Prescription rates assessed by linked Pharmaceutical Benefits Scheme data. Prescription rates assessed by practice Electronic Health Record (EHR) data. Proportion of patients aged < 16 years seen same day as requested assessed by parent / patient report. Proportion of patients aged 18‐65 years with chronic conditions, or aged > 65 years, seen within 1 week of hospital discharge assessed by EHR. Proportion of patients aged 18‐65 years with chronic conditions, or aged > 65 years, seen within 1 week of hospital discharge assessed patient report. Specialist consultation rates assessed by linked Medicare data. INCLUSION CRITERIA: Patient participants will include three groups: a. Older patients (over 65 years); 15 per practice b. Patients 18 ‐ 65 years with chronic and/or complex ambulatory care sensitive conditions (COPD, diabetes, angina, cardiac failure, asthma); 15 per practice c. Patients aged less than 16 years with increased risk of hospitalisation defined by previous high risk diagnosis (e.g. acute bronchiolitis, asthma, pneumonia, croup and vaccine preventable illness); 20 per practice