243pluralism promotes experimentation and the creation of multiple mechanisms,
while systems based upon a “single-payer” principle are often inefficient and slow
to change, albeit with exceptions such as the incentive system recently introduced
by the NHS in the UK. Unfortunately, single payers have a tendency to hew to sin-
gle models, often regardless of whether they work well or not.
The opposing weakness of the US system is the multiplicity of health-care insur-
ers and purchasers, which greatly complicates efforts to create incentives effective
with group practices and hospitals that may deal with patients insured by a plethora
of health-care plans. This situation makes administrative costs high relative to finan-
cial incentives. One possible solution to motivate hospitals and physicians would be
the creation of collaborative programs between large insurers, supported by CMS
(Centers for Medicare and Medicaid Services) [ 44 ], the biggest public sector pur-
chaser. One thousand interviews with 35 health plans across 12 major US metro
areas indicated that 77% of the plans “.. .had hospital- or physician-based pay-for-
performance strategies that were being actively developed or had pilot or full pro-
grams that had already been implemented. Most of the health plan efforts were new,
with about one-third of all reported efforts being in the planning or developmental
stages...(They) uniformly reported that their goal is to reduce costs through improved
quality and provider efficiency.” [ 45 ].
The same cannot be said of QOF – “Quality and Outcomes Framework” of the
UK NHS.
Public Policy Developments in the UK: Financial Incentives
for Physicians
QOF was introduced to general practitioners (GPs) in April 2004 by the NHS as a
voluntary contractual component. In terms of cardiovascular disease and hyperten-
sion, the quality objectives of QOF are preventative to a strong degree, emphasizing
improved outcomes by ensuring patients are on the right medication to meet their
needs and through early and continued monitoring of risk factors, including choles-
terol and BP. The incentives use a “point” system and are rewarded to practices, not
single doctors. Good record keeping and diagnosis are reasons for points, as are
management both initially and ongoing. The most points are awarded for such
improvements of outcomes as meeting or surpassing clinical guidelines across a
broad span of patients [ 46 ]. QOF is widely seen as a leap forward for preventative
care. When it was introduced, an American observer called QOF “.. .the boldest
such proposal attempted anywhere in the world.. .With one mighty leap, the NHS
has vaulted over anything being attempted in the United States, the previous leader
in quality improvement studies” [ 47 ].
Striking differences between QOF and initiatives forwarded in America include:
- Systemic and national extent
- The near unanimity over its goals and methods
15 Public Health Efforts for Earlier Resistant Hypertension Diagnosis...