Exclusion of patients from pay-for-performance targets by English physicians

N Engl J Med. 2008 Jul 17;359(3):274-84. doi: 10.1056/NEJMsa0800310.


Background: In the English pay-for-performance program, physicians use a range of criteria to exclude individual patients from the quality calculations that determine their pay. This process, which is called exception reporting, is intended to safeguard patients against inappropriate treatment by physicians seeking to maximize their income. However, exception reporting may allow physicians to inappropriately exclude patients for whom targets have been missed (a practice known as gaming).

Methods: We analyzed data extracted automatically from clinical computing systems for 8105 family practices in England (96% of all practices), data from the U.K. Census, and data on practice characteristics from the U.K. Department of Health. We determined the rate of exception reporting for 65 clinical activities and the association between this rate and the characteristics of patients and medical practices.

Results: From April 2005 through March 2006, physicians excluded a median of 5.3% of patients (interquartile range, 4.0 to 6.9) from the quality calculations. Physicians were most likely to exclude patients from indicators that were related to providing treatments and achieving target levels of intermediate outcomes; they were least likely to exclude patients from indicators that were related to routine checks and measurements and to offers of treatment. The characteristics of patients and practices explained only 2.7% of the variance in exception reporting. We estimate that exception reporting accounted for approximately 1.5% of the cost of the pay-for-performance program.

Conclusions: Exception reporting brings substantial benefits to pay-for-performance programs, providing that the process is used appropriately. In England, rates of exception reporting have generally been low, with little evidence of widespread gaming.

Publication types

  • Research Support, Non-U.S. Gov't

MeSH terms

  • Contract Services
  • England
  • Family Practice / economics
  • Family Practice / standards
  • Family Practice / statistics & numerical data*
  • Humans
  • Linear Models
  • Patients
  • Physician Incentive Plans*
  • Quality Assurance, Health Care
  • Quality Indicators, Health Care*
  • Risk Adjustment
  • Salaries and Fringe Benefits
  • State Medicine / economics
  • State Medicine / standards*