SAN DIEGO — Pay-for-performance programs must be designed to avoid putting some of the most vulnerable patient populations at risk, officials with the American College of Physicians warned at the organization's annual meeting.
Although pay for performance has the potential to improve medical care, it could also endanger the physician-patient relationship, the financial stability of the health care system, and the elderly and the chronically ill, said Dr. Frederick E. Turton, chair of ACP's Ethics, Professionalism and Human Rights Committee.
ACP is preparing to publish a position paper on the issue of ethics in pay for performance. The paper focuses on what the programs should accomplish, what physicians should do if participating in them, and the potential unintended consequences of these programs.
For example, ACP officials are concerned about programs that base their incentives on meeting strict clinical targets, such as a specific hemoglobin A1c level, because that might prompt physicians to select patients based on their ability to meet that target. Instead, programs that focus on improvement on a measure might be more appropriate, Dr. Turton said at a press briefing. Other unintended consequences include the potential for gaming the system by physicians, and an increase in unnecessary care and costs.
The programs also have the potential to encourage physicians to perform to the measure, rather than evaluating the individual needs of the patients, Dr. Alan R. Nelson, a member of the Institute of Medicine's study committee on pay for performance. And quality measures may not lead to reductions in cost, in fact, in the short term, it will probably increase use of services and cost, he said.
Limited data are available about pay-for- performance ethical concerns, in part because these programs are so new and researchers need more time to study their effects, said Dr. Matthew K. Wynia, director of the Institute for Ethics of the American Medical Association. The programs are also variable, complex, and are often proprietary and confidential, making them hard to study. And pay for performance is generally not well understood by either patients or physicians at this point.
The limited data in the literature has provided mixed results on pay for performance. One study compared the performance of California physicians enrolled in a pay-for-performance program with the performance of physicians in the Pacific Northwest who were not enrolled. It assessed outcomes on cervical cancer screening, mammography, and hemoglobin A1c testing. The California physicians achieved greater quality improvement only in cervical cancer screening. The authors found there was little gain in quality, and the financial rewards were given mainly to those who had a higher performance at baseline (JAMA 2005;294:1788–93).
In another study, 207 hospitals in a Medicare-sponsored pay-for-performance demonstration showed greater improvement in a composite of 10 quality measures, compared with 406 hospitals involved in voluntary public reporting only. In pay-for-performance hospitals, those with the worst baseline quality performance improved the most; those with the highest baseline quality improved least (N. Engl. J. Med. 2007;356:486–96).