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Does pay for performance promote inverse inequality in chronic disease management?
Sarah Linnane1, Sarah Mullarkey1, Eoin Kyne1
1Irish College of General Practitioners Mid-West GP Training Scheme, School of Medicine Building, University of Limerick, Plassey, Limerick V94T9PX, Ireland.
Insights
Patients with state-funded General Medical Services (GMS) care received better chronic disease management than private patients (PPs). Pay for performance (P4P) programmes in Ireland appear to exacerbate these disparities, promoting inequality in healthcare access.
Area of Science:
- Healthcare policy and management
- Public health
- General practice research
Background:
- Ireland operates a mixed public-private healthcare system with General Medical Services (GMS) and private patient (PP) care.
- A practice-level chronic disease management programme, utilizing a pay for performance (P4P) model, was introduced in 2020.
- The P4P programme incentivizes General Practitioners (GPs) to regularly review GMS patients for eight chronic conditions.
Purpose of the Study:
- To investigate the impact of the P4P programme on the standard of care provided to GMS patients compared to PPs.
- To assess whether PPs, receiving routine care, experienced a lower standard of chronic disease management.
Main Methods:
- A retrospective cross-sectional study was conducted across 11 General Practice (GP) settings in Ireland.
- Data from 25 GMS and 25 matched PP patients per practice (total 550 patients) were analyzed.
- Key clinical parameters including vaccination status, blood pressure, smoking status, renal function, HbA1c, and lipid levels were compared.
Main Results:
- General Medical Services (GMS) patients demonstrated significantly higher rates of vaccination uptake (influenza, COVID-19, pneumococcal) compared to private patients (PPs).
- GMS patients were more likely to have essential clinical parameters monitored, including blood pressure, smoking status, renal function, glycated haemoglobin, and lipids.
- All measured parameters showed statistically significant differences (P < .001) favoring GMS patients.
Conclusions:
- Substantial disparities in chronic disease management exist between GMS and PP patients in Ireland.
- The current pay for performance (P4P) model, limited to GMS patients, inadvertently promotes healthcare inequality.
- Policy review is recommended to ensure equitable chronic disease care for all patient groups.
Background:
In Ireland, a mixed public-private system exists, whereby some patients receive state-funded general practice (GP) care under the General Medical Services (GMS), while private patients (PPs) pay fees. In 2020, the chronic disease management programme was introduced at the practice level to enhance the management of eight conditions. This pay for performance (P4P) programme incentivises GPs to review GMS patients regularly using a structured protocol. It is hypothesized that ineligible PPs receiving 'routine care', receive a poorer standard of care.
Objective:
To investigate the effect of P4P on the standard of care between PPs and GMS patients.
Methods:
Retrospective cross-sectional study involving 11 GP practices in the Midwest of Ireland. Clinical parameters recorded for the previous 12 months on 25 GMS patients and 25 PPs, matched by age group, sex, and one clinical condition, were collected from each practice. Parameters included vaccination status, and recording of: blood pressure, smoking status, renal function, glycosylated haemoglobin, and lipids.
Results:
Data from 550 patients showed that GMS patients were more likely than PPs to have received/been offered vaccinations (influenza (66% vs 26%), COVID-19 (69% vs 23%), pneumococcal (59% vs 15%)). GMS patients were more likely than PPs to have other parameters measured: blood pressure (92% vs 54%); smoking status (84% vs 24%); renal function (90% vs 59%); glycated haemoglobin (87% vs 56%); lipids (89% vs 57%) (P < .001 for all parameters).
Conclusion:
Significant disparities exist in the management of chronic disease in Ireland between GMS patients and PPs. Limiting P4P programmes to GMS patients promotes inequality.
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