Ethics Forum: Pay for Performance

Since its introduction some ten years ago, Pay-for-Performance (P4P) has been the object of much confusion, conversation and scrutiny in the medical industry.

Such programs have raised a host of practical questions: What criteria do you use to objectively judge performance? How do you develop incentives for accomplishment and penalties for falling short? What principles do you use to guide such programs?

Practical considerations aside, the payment system has also raised some important ethical questions, and those were the focus of the Ethics Forum at the 2014 MMS Interim Meeting on Friday, December 5 presented by the Committee on Ethics, Grievances and Professional Standards.

Offering their perspectives on the topic of Ethics of Pay for Performance were Alyna T. Chien, M.D., M.S., a pediatrician at Boston Children’s Hospital and the lead investigator in four different projects focusing on the effectiveness of payment and quality incentives, and Sachin H. Jain, M.D., M.B.A., Chief Medical Information and Innovation Officer at Merck and Lecturer in Health Care Policy at Harvard Medical School.

“We are in a revolution,” said Dr. Chien, “as the entire organization of medicine is changing, progressing to one of integrated health care.” She noted that most incentives move from the payer to the hospital or physician practice, and that most of the data regarding the impact of P4P programs exists at the organizational level. There’s little data on how it works at the individual physician level.

Dr. Chien believes these performance programs can have one of three effects in delivering care: a neutral effect, where the status quo is preserved; a narrowing of care, where more attention is paid to quality and more programs are tailored to patients; or a widening of care, where gaps will occur between rich and poor and physicians will selectively pick their patients.

Dr. Jain acknowledged that the public perception of the profession has changed and that physicians should be at “a point of soul searching and questioning where we are in society.” He offered a scenario of physicians as either “knights” (motivated by altruism and being the ultimate champion of the patient), “knaves” (driven by self-interest and financial gain), or “pawns” (pushed by rewards and penalties of the system in which they operate).”

While he pointed out that such a framework can also be applied to others (for example, patients, health plans, pharmaceutical companies, nurses, and hospital executives), Dr. Jain believes organized medicine has focused too much on reimbursement and that physicians are perceived not to be trusted to do what’s right unless there’s a carrot or stick approach.

“We are losing our more intrinsic value in favor of pay-for-performance,” Dr. Jain says, “and the intrinsic motivation of doing what’s right for the patient must be preserved. It is what differentiates us from other professions. It is what tells others that we will do the right thing whether we get paid or not.”

His prescription is direct: a proper system of reimbursement must offer a reasonable salary, reject incentive contracting, focus on clinically meaningful measures, make it easy for physicians to do the right thing for patients, and find ways to honor and reward the intrinsic motivation of what’s best for the patient that most physicians have.

Presentations at the Ethics Forum may be viewed here.

  1. donald bachman md says:

    Dr Jain’s division of doctors into knights,knaves and pawns was a very good tool for analyzing how docotrs act and are perceived by insurers and public. I believe there is a bit of each in most individuals and which traits come foward is likey to be molded by expectation and the environment which can reward altruism or debase it by cynicism or resentment. The following debate was not truly a question and answer on P for P, but really unleashed a lot of the pent up anger and resentment physicians feel about the current environment. This may have been cathartic but did not really address appropriate solutions.

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