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Previous Volume 359:274-284 July 17, 2008 Number 3 Next

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ABSTRACT

Background In the English pay-for-performance program, physicians use a range of criteria to exclude individual patients from the quality calculations that determine their pay. This process, which is called exception reporting, is intended to safeguard patients against inappropriate treatment by physicians seeking to maximize their income. However, exception reporting may allow physicians to inappropriately exclude patients for whom targets have been missed (a practice known as gaming).

Methods We analyzed data extracted automatically from clinical computing systems for 8105 family practices in England (96% of all practices), data from the U.K. Census, and data on practice characteristics from the U.K. Department of Health. We determined the rate of exception reporting for 65 clinical activities and the association between this rate and the characteristics of patients and medical practices.

Results From April 2005 through March 2006, physicians excluded a median of 5.3% of patients (interquartile range, 4.0 to 6.9) from the quality calculations. Physicians were most likely to exclude patients from indicators that were related to providing treatments and achieving target levels of intermediate outcomes; they were least likely to exclude patients from indicators that were related to routine checks and measurements and to offers of treatment. The characteristics of patients and practices explained only 2.7% of the variance in exception reporting. We estimate that exception reporting accounted for approximately 1.5% of the cost of the pay-for-performance program.

Conclusions Exception reporting brings substantial benefits to pay-for-performance programs, providing that the process is used appropriately. In England, rates of exception reporting have generally been low, with little evidence of widespread gaming.

Source Information

From the National Primary Care Research and Development Centre, University of Manchester, Manchester (T.D., C.F., D.R., M.R.); and the National Primary Care Research and Development Centre, Centre for Health Economics, University of York, York (H.G.) — both in the United Kingdom.

Address reprint requests to Dr. Doran at the National Primary Care Research and Development Centre, Williamson Bldg., University of Manchester, Manchester M13 9PL, United Kingdom, or at tim.doran{at}manchester.ac.uk.

Full Text of this Article

Related Letters:

Pay-for-Performance System for English Physicians
Rosof B. M., Sirio C. A., Kmetik K. S.
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N Engl J Med 2008; 359:2176-2177, Nov 13, 2008. Correspondence

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