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How prevalence affects your QOF income

Incorrect coding may mean the prevalence of particular diseases within your practice is not accurately represented - which could result in the practice being underpaid for QOF work. Fiona Lawson explains.

Accurate disease registers could significantly increase QOF income (Image: iStock)
Accurate disease registers could significantly increase QOF income (Image: iStock)

Do you have any idea how much inaccurate data costs your practice and affects patient care?

The data you input into patient records determines their care. If a diagnosis is not entered using the correct read or CTv3 code patients will not be called in for reviews. Data quality is also essential for practice income – in many cases specific codes determine whether you get paid or not.

All practices want to believe that their data is accurate but with so many people entering this data, it is impossible to guarantee accuracy unless you regularly validate your data.

There are in excess of 300,000 codes and the average practice enters over a 250,000 codes each year – how likely is it that everyone in the practice is coding consistently?

Incomes per point

So how much does all this really affect your income? The table below shows the averages used to calculate prevalence payments:

Country Average list size Average £ per patient Total QOF points available in 2014/15 Total income**
England 7,087 £156.92 559 £87,718.28
Wales 6,798 £154.83 669 £103,581.27
Northern Ireland 5,409* £145.35 649 £94,332.15
Scotland 5,622 £133.4 658 £87,823.26

*Based on 2013/14 list size as 2014/15 not yet available

** Based on average list size & practice achieving average prevalence in every disease area

The above calculations are based on averages – if your patient list size is greater than the average list size your average point value will increase, if it is less, it will decrease.

Examples below:

Country Actual  list  size Average  £  per  point
England 3,000 £66.33
11,200 £247.99
Wales 2,000 £45.55
9,700 £220.93
Northern Ireland 4,150 £111.52
12,680 £340.74
Scotland 5,550 £142.13
14,250 £364.92

With the number of QOF points reducing it is even more important to maximise the value of the points you do achieve.

How does prevalence work?

The value of QOF points is based on the burden of a particular disease on your practice – the prevalence of a disease. Many practices just think of QOF in terms of the number of points they can achieve believe their points are worth a set amount. However, if your practice prevalence is lower than the national average, the value of your points drops.

If your prevalence for a specific disease area is lower than the national average, the burden of that disease is lower on your practice and therefore the value of each point is reduced. For example:

Disease QOF points No. on register Practice prevalence National prevalence Actual value of each point
CHD 45 310 2.77 3.34 £205.51
Diabetes 86 342 3.05 4.83 £156.78
Mental health 26 59 0.53 0.84 £155.53

The above is based on points & prevalence rates in England, with a list size of 11,200 patients, average point value £247.99; however, as this is for demonstration purposes it is relative to all four countries.

Using diabetes as an example – the practice (11,200 patients) achieves all 86 points for diabetes and believes it will get £247.99 per point (£21,327.14).

In fact, achieving 86 points will only give them an income of £13,483.08, almost £8,000 less – as their actual value per point is only £156.78.

If this is a true reflection of the burden of diabetes on the practice it stands to reason they will get paid less. However, if this is due to a data quality issue, this will be costing your practice hundreds of pounds.

Adding 10 patients onto the diabetic register will increase your income by approximately £400 per year. Most practices would not think they could miss 10 diabetic patients, however, you will be surprised how many patients you know are diabetic who have never had the correct diagnosis code added to their records. If this is the case, practices may be doing the work but they are not actually on the register.

Other disease areas may be reliant on using episodes to include them on the register as well as a diagnosis, for example cancer or MIs. This usually occurs where a diagnosis can occur more than once. By not including ‘new’ or ‘first’ episode when entering the diagnosis will preclude the patient’s inclusion on the register. This lack of understanding around your clinical system will again be very costly, both to the patient’s care and the practice’s income.

Validating disease registers

If practices do not regularly validate their QOF disease registers the practice may be losing hundreds of pounds.

So why don’t practices just validate their own data? More often than not it just comes down to time – staff are already so busy. The content of the validation searches involves clinical, admin and medication entries so a clinician and administrator would need to set this up. This can be time consuming.

Practices can employ a third-party company to do this work. Some companies offer this service for a set fee, while others take a percentage of the findings – the latter can prove costly.

However, practices could find they can increase their QOF income from anything between £2,000 and £45,000 by ensuring their coding is correct and all of the patients diagnosed with a condition are correctly identified as such and included on their disease registers.

Based on the quality assessments we have conducted, the average loss of income due to inaccurate prevalence is approximately £9,200 per practice per annum.

  • Fiona Lawson is managing director of Insight Solutions, a company that offers on-site data quality assessments for practices. For more information call 01527 557407 or email Fiona@insightsol.co.uk.

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