Pay for Performance in Primary Care in England and California: Comparison of Unintended Consequences

Somehow I missed this one.  This article has parallel important analyses.

Unintended consequences reported by physicians varied according to the incentive program. English physicians were much more likely to report that the program changed the nature of the office visit. This change was linked to a larger number of performance measures and heavy reliance on electronic medical records, with computer prompts to facilitate the delivery of performance measures. Californian physicians were more likely to express resentment about pay for performance and appeared less motivated to act on financial incentives, even in the program with the highest rewards. The inability of Californian physicians to exclude individual patients from performance calculations caused frustration, and some physicians reported such undesirable behaviors as forced disenrollment of noncompliant patients. English physicians are assessed using data extracted from their own medical records, whereas in California assessment mostly relies on data collected by multiple third parties that may have different quality targets. Assessing performance based on these data contributes to feelings of resentment, lack of understanding, and lack of ownership reported by Californian physicians.

The use of P4P is, in my opinion, immoral.  P4P changes physician behavior, and it is unlikely that that change is an improvement.

The underpinning idea of P4P is that it will improve patient outcomes.  We have no evidence that this theory will work.  If I introduce a new drug, I must jump through many hoops showing both efficacy and lack of significant harm.  The gurus of EBM insist on evidence for treatments and diagnostic tests – and they are right.

We need an outcry about P4P, which has no evidence behind the concept.  It is immoral because the predictable unintended consequences are not good for patient care.

Our study findings suggest that unintended consequences of incentive programs relate to the way in which these programs are designed and implemented. Although unintended, these consequences are not necessarily unpredictable. When designing incentive schemes, more attention needs to be paid to factors likely to produce unintended consequences.

Nice study but they clearly do not understand motivation.  Incentive schemes are bound to fail. Physicians want to do the right thing for their patients.  We can motivate better with incentive schemes.  We should ban this practice in the US.

Related posts:

1. P4P has negative externalities
2. Measurement – the good and bad
3. Comparative effectiveness research – more thoughts
4. Unintended consequences – more on pneumonia
5. Physicians and the pharmaceutical industry

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