MERIT PAY FAIL
GP performance pay fails to drive lasting changes in quality of care
Financial incentives alone are no magic bullet to improve quality, say researchers
Introducing performance related pay for UK general practices initially improved quality of care, but did not seem to provide lasting improvements beyond that expected by previous trends, finds a study published by The BMJ today.
And initial gains in quality seemed to reverse when financial incentives were withdrawn, say the researchers.
The UK Quality and Outcomes Framework (QOF) pay-for-performance programme was introduced across the NHS in 2004 to reward general practices for providing high quality care across a range of disease indicators such as cancer, diabetes, heart disease, mental health, and obesity.
In 2014, a large number of QOF indicators were withdrawn, and in 2016 Scotland abolished the scheme, giving researchers an opportunity to examine its short and medium term impact.
To do this, they reviewed 11 studies of the impact of introducing QOF incentives for 83 indicators and withdrawing incentives for 31 indicators at a minimum of three time points before and after QOF began.
Although the design and quality of the studies differed, their risk of bias was low.
Compared with predicted levels of quality based on prior trends, QOF incentives were associated with improvements in recorded quality of care across all indicators at one year (average increase 6.1% beyond that expected), but improvement in quality was less consistent at three years (average increase 0.7%).
In contrast, incentive withdrawal led to a decline in recorded quality of care at both one and three years (average decreases of 10.7% and 12.8%, respectively), suggesting that the effects of pay-for-performance programmes are often not sustained without continued financial motivation.
Complex process indicators, such as foot screening in patients with diabetes, had larger declines than simple process indicators (for example, blood pressure measurement), intermediate outcomes (for example, blood pressure control), and treatment indicators (for example, anti-clotting therapy).
At three years, small declines in the quality of non-incentivised care was also found, suggesting that the focus on incentivised conditions may have come at the expense of important but non-incentivised aspects of healthcare.
These are observational findings, so no firm conclusions can be drawn about cause and effect, and the authors acknowledge that they could not distinguish changes in data recording from changes in the care actually provided to patients, and that some indicators were already near maximum before incentivisation, limiting likely benefit.
Whether or how best to deploy financial incentives in primary care remains uncertain, although financial incentives may have a role for engaging practices in broader quality improvement initiatives, the study authors conclude.
These findings raise important questions about the value of pay-for-performance programmes for patients, clinicians, and policy makers, say researchers in a linked editorial.
They point out that, as health systems globally continue to grapple with the challenge of improving quality of care in an era of financial restrictions, the lessons from the QOF programme in the UK can help in developing more effective and sustainable approaches to incentivising high quality primary care.
An effective QOF programme that focuses on key clinical areas and that makes best use of developments in information technology remains essential for the NHS if we are to reduce health inequalities, increase healthcare efficiency, and improve health outcomes, they conclude.
Journal
The BMJ
Method of Research
Systematic review
Article Title
Effect of UK Quality and Outcomes Framework pay-for-performance programme on quality of primary care: systematic review with quantitative synthesis
Article Publication Date
25-Jun-2025
COI Statement
All authors have completed the ICMJE uniform disclosure form at www.icmje.org/disclosure-of-interest/ and declare: support from the Economic and Social Research Council and Legal and General Group; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Can targeted payment adjustments help solve the infectious disease physician shortage?
A new analysis examines the first specialty-specific add-on code for Medicare infectious disease services
Key Points:
- Infectious disease (ID) physicians are among the lowest paid of all medical specialties, leading to declining interest among medical students and a national shortage.
- To address this, the Centers for Medicare and Medicaid Services (CMS) introduced a new add-on code increasing payments by ~20% in 2025, the first specialty-specific workforce incentive in the Medicare fee schedule.
- This new analysis offers three recommendations for CMS to guide implementation and evaluation of this new payment model.
Boston, MA – A new analysis by researchers from the Harvard Pilgrim Health Care Institute examines the first Centers for Medicare and Medicaid Services (CMS) add-on code targeting a single physician specialty: infectious disease (ID). The measure is a significant departure from the agency’s past strategies, with the potential to combat the growing shortage of ID physicians and broader implications for physician reimbursement and healthcare delivery, according to the authors.
The Viewpoint, “Raising Reimbursement Rates to Combat Specialty Physician Shortages: A New Federal Initiative” was published on June 25 in JAMA.
Despite the vital role ID doctors play in critical public health functions such as pandemic preparedness and antimicrobial stewardship, they are among the lowest paid of all medical specialists. This imbalance between expertise and pay has contributed to a declining interest in the field, leaving half of ID fellowship positions unfilled in 2024. As a result, the U.S. faces a growing shortage of ID physicians, with an uneven distribution that disproportionately affects vulnerable and rural populations.
In response to ID physician discontent, the 2025 Medicare Physician Payment Final Rule included a new add-on code (G0545) for inpatient ID consultations, increasing reimbursement by $28.80 per inpatient ID consultation, an increase of approximately 20% on average over prior compensation levels. The services eligible for the add-on code include disease transmission risk mitigation, public health investigation, analysis and testing, and complex antimicrobial counseling and treatment.
“Infectious disease physicians are at the frontlines managing COVID-19 as well as future pandemics, yet their compensation is within the lowest quartile of all physician compensation,” said lead author Hao Yu, Harvard Medical School associate professor of population medicine at the Harvard Pilgrim Health Care Institute. “The add-on code is a meaningful recognition that ID physicians are under-compensated relative to the complexity and intensity of their work, but it remains to be seen whether it will improve ID physician salaries and workforce.”
The authors emphasize that, compared to other physician-shortage incentive payment programs, the new ID add-on code does not have a time limit, offers a higher reimbursement increase, and is specialty-specific. They note that while this novel strategy put forth by CMS appears promising, additional steps should be considered while implementing and evaluating the new code. They make three recommendations:
- Ensure the payments translate to increases in physician salary: Efforts are needed to support the complexity of their services rather than the add-on payments being billed by the hospital but not translating to physician salary. For example, CMS could tie payment of the add-on code with transparent reporting from hospitals about ID specialist compensation in their annual cost reports, which are audited by Medicare. This policy lever would be similar to the New Technology Add-on Payment that requires hospital attestation with compliance via Medicare auditing.
- Add location-based incentives: To help alleviate the critical shortage of ID specialists in rural and underserved areas, the add-on code should be extended with a higher reimbursement rate specifically for these areas.
- Treat the ID add-on code as a pilot test: Carefully monitor and evaluate the effectiveness of the add-on code to determine whether it is a viable solution to combat shortfalls in ID specialties before implementing similar measures for other specialties.
The authors note that Medicare’s outsized influence on commercial payer fee setting means that the new add-on code has the potential to reset national benchmarks for ID compensation if done effectively. “Medicare is sending a strong signal that Infectious Disease expertise is worth more than our current payment system recognizes,” noted Tarun Ramesh, senior author of the study and research fellow at the Harvard Pilgrim Health Care Institute. He adds, “But if hospitals do not pass the bonus through to physicians, shortages in this specialty will continue to adversely affect patient care access and health outcomes.”
About the Harvard Pilgrim Health Care Institute’s Department of Population Medicine
The Harvard Pilgrim Health Care Institute's Department of Population Medicine is a unique collaboration between Harvard Pilgrim Health Care and Harvard Medical School. Created in 1992, it is the first appointing medical school department in the United States based in a health plan. The Institute focuses on improving health care delivery and population health through innovative research and education, in partnership with health plans, delivery systems, and public health agencies. Follow us on Bluesky, X, and LinkedIn.
Journal
JAMA
Article Title
Raising Reimbursement Rates to Combat Specialty Physician Shortages A New Federal Initiative
Article Publication Date
25-Jun-2025
