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Contracts commissioning and conflicts 20 jul


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Contracts commissioning and conflicts 20 jul

  1. 1. Contracts, commissioning and contracts Ruth Thorlby Senior Fellow in Health Policy Nuffield Trust09 March 2012 © Nuffield Trust
  2. 2. ££ Decision to refer/prescribe/treatClinic Clinic A C Clinic B © Nuffield Trust
  3. 3. Clinical Commissioning: GMC guidance on conflicts ofinterest“You must act in your patients best interests when makingreferrals and when providing or arranging treatment or care”“If you have a financial or commercial interest in a business casebeing considered by your Primary Care Trust under PracticeBased Commissioning arrangements, you should declare yourinterest and exclude yourself from related decisions inaccordance with the Department of Health and your PCTsguidance” © Nuffield Trust
  4. 4. Conflict of interest: evidence from the USStudy of physician owned groups in CaliforniaCapitated budget for patient careIf care costs less than budget, groups keep the savingsStrong incentive to undertreat: © Nuffield Trust
  5. 5. Insurance companies Capitation fee $ $ $ negotiated annually, paid monthly Physician group or IPA Primary Drugs care Specialists Imaging Hospitals Groups take risk for some or all of these servicesGroups use a combination of salaries, bonusesand fee for service to pay physicians
  6. 6. Add title here“We don‟t want to pay them for not referring. Theorganization is influenced by the rate of referrals, but itshould not figure at the level of the individual physician.”[Medical director, medical group]“There are no utilization [reduction] incentives in contractswith our doctors. We could be crucified if it was in ourcontracts. And we have to call it something else, like„variability reduction.” [Medical director IPA] © Nuffield Trust
  7. 7. Evidence from NHS?“A group of GPs…have decided to set their own limited companyup to tender a bid to the PCT to take the workload on.And, interestingly, one of the GPs that is on that public limitedcompany also sits on the committee that is making the decision asto where the funding will be allocated in terms of which tenderedbid will be looked on most preferentially by the PCT”Goodwin et al, Practice Based Commissioning, King‟s Fund 20084 Case study sites: all had conflicts of interest © Nuffield Trust
  8. 8. Government’s response?•Enhanced governance arrangements, including two lay members•Meet in public•Publish details of contracts•Governing body to adhere to Nolan principles of public life•“we will revise the provisions in the Bill on the quality premium” © Nuffield Trust
  9. 9. GP contract?“.. a prescriber shall order any drugs, medicines and applianceswhich are needed for the treatment of any patient who is receivingtreatment under the contract by issuing to that patient aprescription form” (GMS Regs, sched 6 para 39) © Nuffield Trust
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