Does pay for performance promote inverse inequality in chronic disease management?

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.