The majority of American physicians
— 73% — support a pay-for-performance (P4P)
funding system for individual physicians, according
to the results of a new survey published in the current
issue of Health Affairs. But the same survey,
which polled 556 American general internists, also found
that 68% were not in favour of public reporting of their
quality measures.
The apparently contradictory results
are less confusing if you look carefully at the wording
of the questions, explained lead investigator Dr Lawrence
Casalino, an assistant professor in the Department of
Health Studies at the University of Chicago. The first
question asked whether they agreed with the statement
"If the measures are accurate, physicians should be
given financial incentives for quality." The key, said
Dr Casalino, is in those first five words.
"'If the measures are accurate'
is a big caveat," Dr Casalino said, "because less than
a third think the measures are accurate." The survey
revealed that most doctors just don't trust the government
and health authorities on the accuracy of these measures.
But despite these physician misgivings, P4P looks set
to expand across the US and, eventually, to Canada.
WHAT
R U P4P?
P4P programs vary from place to place, but what's common
to all of them is the connection of quality measures
to financial incentives. For instance, a typical measure
is an annual calculation of the percentage of women
in a family physician's practice who got a mammogram
in the past year — or the percentage who were notified
by email or phone about coming in for a mammogram. (P4P
is almost exclusively used for primary care physicians,
not specialists.)
"The measures are quite basic and
the things they measure are reasonably important," said
Dr Casalino. "But physicians point out these things
measure a small fraction of what they do and there are
other things that don't get measured." A commonly cited
example of an unmeasurable process is diagnosis —
perhaps a GP's most important role.
"P4P is sometimes talked about
as incentives for trying harder," said Dr Casalino,
"but that is wrong — physicians are already trying
hard. It is really about getting physicians to organize
care, to set in place processes to improve quality,
like setting up automated mail or email or phone reminders
to get women in to get a mammogram."
P4P programs are sometimes combined
with public reporting systems, which serve as yet another
incentive for physicians to improve the quality of their
care.
PERVERSE
INCENTIVES
The accuracy of doctor assessments is far from the only
criticism levelled against P4P. There are concerns that
the extra bureaucracy created by the system would erode
physician autonomy, because an incentive system will
mean that administrators (non-MDs) could potentially
make decisions about how to treat patients. So doctors'
attention might be misallocated to relatively unimportant
things that are measured instead of important things
that are not — critics call these "perverse incentives."
Another potential stumbling block
for P4P is the way it rates doctors who treat disadvantaged
populations. From past experience in the US and UK,
it's been observed that those patients — who often
lack reliable transportation or who cannot speak the
doctor's language well — will come in less often
for mammograms and other regular check-ups — driving
down a doctor's quality measures. This raises fears
that a P4P system could give incentives to doctors to
avoid treating sick or noncompliant patients —
a potentially huge perverse incentive that could increase
class disparity. (That problem has already been observed
on a large scale in New York by Dr Rachel Werner, who
studied the effect of public reporting on cardiac surgeons'
racial profiling.) "One way to deal with that would
be to pay for the absolute score [on a quality measure],
and for improvement," said Dr Casalino. "If you start
off poorly [in a measurement area], you can get paid
more for improvement."
Another solution to that problem
has already been adopted in the UK, where doctors can
now enact an exclusion clause that allows them to exclude
a percentage of patient records they do not consider
representative of their practice.
WARNING
SIGN
The conditional support for P4P indicated by the new
survey should be a warning sign for the policymakers
looking to implement P4P systems, said Dr Casalino.
This is a critical period, he said: "The time to address
[doctors' worries] is now, before physicians squawk
about what a lousy system it is."
Canada must also proceed with caution,
said Dr Thomas Feasby, a University of Alberta neurologist
and co-author of the 2006 Law & Governance
essay "Pay for Performance — Can It Work In Canada?"
PRUDENT
LAGGARDS
Canada is a step behind the United States in introducing
P4P, and several leaps behind the UK, but we may soon
be joining our international peers in changing the way
doctors are paid.
"In a way we are just as well to
be lagging behind," said Dr Feasby. "Maybe we're a little
more cautious here, but we can learn a lot from the
US and the UK."
A compromise might be struck between
P4P and our current pay-for-volume, suggested Dr Feasby,
but he nevertheless insists that P4P is inevitable in
Canada in one form or another.
In fact, P4P is already on its
way in Canada. Discussions have begun in Alberta, said
Dr Feasby, though no action has been taken there yet.
And Ontario is considering P4P in its long-term planning.
A recent Ontario Ministry of Health and Long-Term Care
essay called "Sustainability through Supply Manage-ment"
proclaims that "[m]ore and more research demonstrates
a positive effect of pay-for-performance on quality
objectives." The paper recommends that policymakers
take a closer look at P4P.
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