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Pay-for-performance: physicians as pets
Editorial board member discusses how P4P may hinder physician flexibility in treating patients.
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Dogs competing each year at the Westminster Kennel Club Show are impressive. They represent the American ideal of what a pet should be, performing tasks expertly and on command while their trainers discreetly feed them treats at each turn. It is the essence of pay-for-performance – jump through a hoop and get a reward.
Similarly, a P4P approach to delivering health care will position U.S. physicians as pets – receiving compensation for jumping through bureaucratic hoops rather than for using clinical judgment to provide quality patient care. Incorporating rhetoric such as “evidence-based medicine” and “best practices” into P4P schemes, proponents are creating the false impression that such an approach would improve the quality of health care, promote market-like competition, and control costs.
In July, CMS reported that quality was improving and savings being generated in the first year of its Medicare Physician Group Practice Demonstration involving P4P. In the three-year study, receipt of a bonus is contingent upon achieving various clinical benchmarks and whether the Medicare growth rate in spending for a group is at least 2% lower than comparison populations in its local markets. Some of the groups met the benchmarks but did not receive a bonus because of this 2% hurdle.
Is the ultimate driver cost rather than quality? If it is cost, will this pressure the physicians in the remaining two years of the study to decrease quality in an attempt to lower cost and receive a bonus? Time will tell.
Rewards do not improve compliance
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Another CMS pilot project involving hospitals revealed that financial incentives did not significantly improve compliance with guidelines. Those hospitals receiving bonuses made significant improvements in the care of cardiac patients just like the hospitals that didn’t receive bonuses. The authors concluded: “The results of the study raise concerns about what magnitude of effect pay-for-performance programs should have to justify the administrative burden and potential unintended consequences of financial incentives.”
According to Alfie Kohn in Punished by Rewards, “. . . not a single controlled study has ever found that the use of rewards produces a long term improvement in the quality of work. In fact, experimental simulations continue to suggest that the opposite is true. … those individuals who are committed to excellence and likely to do the best work are particularly unlikely to respond to financial incentives.”
Financial incentives regularly produce short-term quantitative gains in performance (how many, how fast, etc.) but only if the tasks are simple. And those gains disappear if one looks at quality, Kohn found.
Consider the many pressures physicians are under to do their best. The first and most powerful is that they are treating a fellow human being who has come to them seeking relief from pain or suffering. There is also the intellectual challenge of finding the best way to treat the patient. There is an issue of pride and reputation. Rising to the occasion and proving to oneself and others that you are skilled enough to correct the problem provide incentive and satisfaction. And if these were not enough incentive to do one’s best, there is always the ever present threat of a malpractice case.
Given all of these incentives and pressures, will giving the physician a reward in the form of a few more “shekels” make his or her performance even better? I think not.
Rewards, an interference
In fact, rewards could make physicians perform worse. Janet Spence, PhD, past president of the American Psychological Association, said: “Rewards have effects that interfere with performance in ways that we are only beginning to understand.” They could result in a deterioration of creativity, innovative ability and medical judgment.
With compensation hinging on adherence to protocols and guidelines, physicians will become highly skilled at adhering to them. As they treat the practice of medicine as if it were an SAT exam, with right and wrong answers and grades handed out by the government, their ability to be flexible, innovative and discerning in patient care will suffer. Focused on the specific tasks that are linked to financial rewards, automatic practitioners of government-prescribed behaviors will replace doctors who are skilled in combining multiple sources of knowledge with their best medical judgment in providing patient care.
The most important element that a physician brings to the patient-doctor relationship is his best medical judgment. But basing payment on behavior will pressure the doctor to change his criterion for decision making from that which is “medically necessary” to that which is “medically necessary for the patient and financially tolerable for the doctor,” according to Stone et al.
And, what of the patient? Is he not an integral part of the treatment plan? What if he doesn’t follow the treatment protocol as directed? From the physician’s perspective, the patient-doctor relationship changes dramatically when the patient’s actions determine the physician’s compensation. If the patient does not follow the physician’s treatment plan, does not take medication as prescribed or continues to engage in risky behavior, adverse results can occur. These will be reflected in the physician’s rating and thus in the physician’s P4P compensation.
Physicians can’t control their patients. Weathermen can’t control the weather. What if weathermen were paid on a P4P basis? “Would throwing them a bone improve the weather?”
Richard Dolinar, MD, is a senior fellow in Healthcare Policy at the Heartland Institute, Chicago, a clinical endocrinologist in private practice in Phoenix, AZ, and a member of Endocrine Today’s Editorial Board.
For more information:
- Glickman SW, Ou FS, DeLong ER, et al. Pay for performance, quality of care, and outcomes in acute myocardial infarction. JAMA. 2007;297:2373-2380.
- Kohn A. Punished by Rewards: The Trouble with Gold Stars, Incentive Plans, A’s, Praise, and Other Bribes.1999. Houghton Mifflin.
- Spence JT. Do material rewards enhance the performance of lower-class children? Child Dev. 1971;42:1469.
- Stone DA. The doctor as businessman: the changing politics of a cultural icon. J Health Polit Policy Law. 1997;22:533-56.