CME Author: Charles Vega, MD
The American College of Physicians has issued recommendations to offset the potential adverse effects of pay-for-performance programs and to redirect the focus to the patient. Their position paper, which highlights the ethical implications of pay for performance and potential effects on the clinician-patient relationship, is published in the December 4 issue of the Annals of Internal Medicine.
“Pay-for-performance programs are growing, but little evidence exists on their effectiveness or on their potential unintended consequences and effects on the patient-physician relationship,” write Lois Snyder, JD, and colleagues from the American College of Physicians Ethics, Professionalism and Human Rights Committee. “Pay-for-performance has the potential to help improve the quality of care, if it can be aligned with the goals of medical professionalism. Initiatives that provide incentives for a few specific elements of a single disease or condition, however, may neglect the complexity of care for the whole patient, especially the elderly patient with multiple chronic conditions.”
The definition of pay for performance is combining performance measurement with financial incentives to motivate clinicians and systems change. Although such programs are becoming increasingly popular, they are also controversial because they introduce conflict between the clinician’s obligation to the patient and financial rewards for good quality ratings.
The study authors state that pay for performance could result in the deselection of patients if clinicians “play to the measures” or “game the system” and shift their focus from the patient as a whole. Clinicians may attempt to improve their ratings on various performance measures by dropping elderly patients with complex medical problems, because the outcome measures of these patients will worsen the clinician’s overall profile.
If financial incentives reward good performance on a few, limited measures of a single disease, this could result in neglect of other, possibly more important elements of care for that disease or for a comorbid disease of greater consequence to the patient’s overall well-being.
Another unintended harm could be misalignment of perceptions between clinicians and patients, because patient care is based on trust. Quality measures important to patients include access to trusted clinicians, continuity of care, empathy, sufficient time for office visits, and coordination of care. These aspects of patient care are often difficult to measure and may therefore be overlooked by pay-for-performance programs.
Finally, pay for performance may increase unnecessary care and medical costs. Not all patients with the same condition need the same intensity of care, so pay-for-performance programs enforcing the same quality measures to all patients fail to recognize that disparity.
“The primary focus of the quality movement in health care should not be on ‘pay for’ or ‘performance’ based on limited measures, but rather on the patient,” the study authors write. “The American College of Physicians hopes to move the pay-for-performance debate forward with a patient-centered focus — one that puts the needs and interests of the patient first — as these programs evolve.”
Specific actions that the study authors recommend to offset these adverse effects of pay-for-performance programs are as follows:
* Ensure transparency for patients concerning financial incentives to clinicians that may be at odds with patient interests, as well as clinician performance on quality measures.
* Measure what is important to patients by developing objective measures of continuity, communication, respect for patient preferences, and confidentiality.
* Monitor unwanted clinician behavior, such as deselection or reluctance to accept patients with complex medical problems, and intervene to prevent these outcomes.
“Pay-for-performance programs and other strong incentives can increase the quality of care if they purposely promote the ethical obligation of the physician to deliver the best-quality care to her or his patient,” the study authors conclude. “Current incentives could result in deselection of patients, ‘playing to the measures’ rather than focusing on the patient as a whole, loss of trust between physicians and patients, unnecessary care, reduced access to care and continuity of care, and worse care for patients with complex chronic conditions. These consequences are avoidable, but only if the architects of the health care system try to avoid them.”
Clinical Context
Pay-for-performance models of clinician reimbursement have been embraced as a means to improve the quality of healthcare, but a systematic review by Petersen and colleagues, which appears in the August 15, 2006, issue of the Annals of Internal Medicine, questions this assumption. These authors found 17 studies for review, most of which focused on incentives for preventive care. Most studies found that financial incentives could be at least partly effective in improving the specific outcomes related to this payment. However, 1 study suggested that pay for performance could also be associated with a lack of care for patients who are more seriously ill who could contribute to failure to achieve incentives, and another study suggested that pay for performance improved documentation more than it improved actual care outcomes. No studies addressed the optimal duration of pay-for-performance incentives or the sustainability of treatment effects after these incentives were removed.
The current position paper from the American College of Physicians offers a critique of the current model of pay for performance and offers suggestions for improving this incentive system.
Study Highlights
* The study authors were concerned by the limited scope of clinical practice parameters used in pay-for-performance systems, believing that this may lead to a lack of attention to other patient issues and, in fact, patient well-being as a whole.
* Other concerns with the current systems of pay for performance included the following:
o Deselection of difficult patients to score higher on incentive systems.
o Misalignment of perceptions between patients and clinicians. Specifically, trust between patient and clinician may be eroded if the clinician is acting in his or her best financial interest, but not in the overall interest of the patient’s health.
o Increase in unnecessary care and medical costs. Patients with the same disease have varying needs, and applying the same standard to all patients could result in added interventions and costs without any substantial disease benefit.
* The study authors suggest the following actions to address these concerns:
o Ensure transparency of the process for both patients and clinicians. This will address the issue of potential mistrust between patient and clinician.
o Measure what is important to patients. The study authors call for the development of objective measures of continuity, communication, respect for patient preferences and confidentiality, and access to care. These measures can then be built into a patient-centered pay-for-performance model.
o Administrative oversight of the process to avoid a lack of access for patients who are more seriously ill because of incentives related to pay for performance.
Pearls for Practice
* A previous systematic review found that most research into the efficacy of pay for performance focused on incentives for preventive care. The majority of studies demonstrated a positive result on the measure being provided with incentives, but no studies have addressed the optimal duration of pay-for-performance incentives or the sustainability of treatment effects after these incentives were removed.
* The current position paper from the American College of Physicians suggests transparency for the pay-for-performance process, measurement of outcomes that are important to patients, and oversight of the pay-for-performance process to avoid systematic abuse.
