What Happens When Pay for Performance Stops?

No evidence of serious harm so far, but future changes need evaluation.

Financial incentives for quality in pay for performance programmes are an attractive improvement method for healthcare payers worldwide, and the UK Quality and Outcomes Framework (QOF) is still one of the largest such programmes. Evidence shows that the QOF improved incentivised quality of care and reduced variation between practices. However, the effect for most indicators was relatively small, was not always persistent, and was partly balanced by negative effects on non-incentivised care. The QOF and pay for performance more generally are therefore clearly not magic bullets for improvement, and many uncertainties remain. The paper by Kontopantelis and colleagues examines one of these important uncertainties—what happens when financial incentives for quality are withdrawn.

Removal of incentivised indicators has several rationales, including lack of initial effectiveness, lack of continued improvement, and to allow the targeting of other priority areas. Over the nine years of the QOF’s existence, large changes to structural and organisational process indicators have been made, but relatively few indicators relating to clinical care have been retired. Instead, funding to introduce new clinical indicators has come largely from reallocating resources from organisational indicators. More radical change was constrained by concerns that withdrawing clinical indicators risked reduced delivery of important care. This fear was supported by evidence from two US studies, in which removal of financial incentives was associated with significant declines in performance, which in one case fell below the pre-incentive baseline.