The Pitfalls of Linking Doctors’ Pay to Performance

This article highlights a conundrum in healthcare.
Doctors are unable to compete in a free-market on the basis of outcomes and receivers of healthcare are unable to accurately assess the quality of the care they receive.

The fundamental problem is that it is extremely difficult to "grade" a process as complex and variable as healthcare delivery--variables that have to be accounted in a single patient encounter may include complexity of disease, other disease interactions, patient compliance, quality of ancilliary health personnel, availability of adequate equipment, decision making processes, technical proficiency, insurance mandated limitations on care etc....

The "pay for performance" title is a complete misnomer (and really rubs me the wrong way) in that it does nothing of the sort. The financial incentive is meaningless except for very large organizations and using very small measures of performances as proxies for quality is potentially fraught with error. Further, I can't see documenting more than I already do. I already an insane amount of time documenting non-relevant details on patient charts for insurance companies and potential adversarial attorneys--which demoralizes me, costs a ridiculous amount of money, and causes patient wait times to continually increase...

(But at least I am not mandated to do preoperative rectal exams for cataract patients as I was during my residency).

Not only that but the pay for performance program in its current iteration is potentially harmful as illustrated below...


The program is called pay for performance, P4P for short. Employers and insurers, including Medicare, have started about 100 such initiatives across the country. The general intent is to reward doctors for providing better care.

For example, doctors receive bonuses if they prescribe ACE inhibitor drugs to patients with congestive heart failure. Hospitals get bonuses if they administer antibiotics to pneumonia patients in a timely manner.

On the surface, this seems like a good idea: reward doctors and hospitals for quality, not just quantity. But even as it gains momentum, the initiative may be having untoward consequences.

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Whenever you try to legislate professional behavior, there are bound to be unintended consequences. With surgical report cards, surgeons’ numbers improved not only because of better performance but also because dying patients were not getting the operations they needed. Pay for performance is likely to have similar repercussions.

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Doctors have seldom been rewarded for excellence, at least not in any tangible way. In medical school, there were tests, board exams and lab practicals, but once you go into clinical practice, these traditional measures fall away. At first glance, pay for performance would seem to remedy this problem. But first its deep flaws must be addressed before patient care is compromised in unexpected ways.