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How to make "pay for performance" pay
Submit responseTo the Editor:
Medical journals are replete with discussions about pay for performance plans for reimbursement of primary care services for chronic disease management (1,2). Pay for performance proponents hold that economic incentives can drive physician behavior, and in turn “improve” the care rendered. However, legitimate concerns have been raised including inaccurate data acquisition by payors and imperfect information linking specific data variables to health outcomes. Cherry-picking by providers to avoid treating the more complexly ill patient is inevitable (and further will likely fall disproportionately to Internists as compared to other primary care providers). This may result in access problems for the most sick and vulnerable patients, and frustration for Internists. Finally, perceptive primary care practices will aggressively dismiss poorly compliant patients who by their behavior place the practice’s performance “at risk.” This may increase overall costs of care as these patients rely on emergency departments for care.
The fundamental question of what pay for performance programs are attempting to reward, and how successful they would be in doing so, is unanswered. One report of a pay for performance program on the West Coast demonstrated that paying based on achievement of specific targets rewarded those practices with the best performance at baseline most. Those who improved performance most received only a small proportion of bonus payments (1).
Physicians have the knowledge to provide proper care to our patients. We are familiar with breast, colon and cervical cancer screening guidelines. We understand ADA recommendations, NCEP guidelines, and JNC-7 algorithms. We are stymied by patients who are collectively overweight, burdened by high pharmaceutical costs, and less than fully compliant with prescribed treatments.
To be sure, physician services (especially primary care) need substantial across the board reimbursement increases. Paying providers performance “bonuses” is problematic and unproven to affect patient outcomes. There is room for other creative ideas in the arena of improving the nation’s health at a reasonable cost. How about providing incentives to patients instead of providers? For example, a system of pay for performance whereby Medicare patients are eligible for semiannual 10-15% rebates of their premiums based on the ability to achieve pre-specified targets. To be certain, the devil is in the details, but such a system could finally ally patient, provider and payor with a unified goal, improve outcomes, and reduce health care costs. Truly a win-win-win situation.
Lawrence (3) insists, “We urgently need to change course.” This idea is a start.
Glenn S. Ross, MD, FACP
1. Rosenthal MB, Frank RG, Li Z, et al. Early experience with pay for performance. JAMA. 2005; 294:1788-1793.
2. Wolff JL, Boult C. Moving beyond round pegs and square holes: restructuring medicare to improve chronic care. Ann Intern Med. 2005; 143: 439-445.
3. Lawrence DM. Chronic disease care: rearranging the deck chairs. Ann Intern Med. 2005; 143: 458-459.
Conflict of Interest:
None declared