Challenges and Unintended Consequences

Many potential burdens of P4P have been described in the literature and are commonly labeled unintended consequences of P4P. Yet few have been demonstrated empirically. If P4P is to fail, it will likely fail because of unintended consequences which challenge physicians and cause them to make poor choices. Many authors (2430113228232274279) provide general ethical warnings about P4P implementation. Hayward (159) provides six ethical dilemmas facing clinicians in a satirical fashion. 

Anticipating and avoiding potential moral challenges upon implementation has been frequently suggested (66108150). Articles provided by Sheldon (96) and Hedgecoe (108) show that incentives to cut costs may have further adverse effects, especially upon financially constrained clinics. Mansfield (79) and Eikens (256) provide personal accounts that physicians may already be considering gaming P4P for financial gain, rather than true quality improvement. These articles all provide support for deliberate consideration of the proposed challenges to P4P before they manifest on a large scale.

One of the most notable moral challenges to P4P is overcoming the problem of selecting patients. Practices know this as "cherry picking" patients with the best outcomes and "lemon dropping" patients with the worst outcomes. Yet many P4P programs are ill equipped to deal with the incentive they provide to cherry pick. The concept of firing patients and choosing compliant patients is mentioned in many articles, and is commomly associated with risk adjustment (see topic #3).

Another frequently cited challenge to P4P is its potential to compromise physician autonomy. Mangin (214) discusses the potential negative impact of P4P on professionalism. Larriviere (172) and Satin (244) raise the point that metrics must somehow account or evolve when evidence conflicts the metric (also see the section on "Controversial Issues: Disputing Guidelines.") Additionally, the threat of "cookbook" medicine (Fanestil, 246) is a common challenge of P4P.

 

 

Challenges and Unintended Consequences Literature

 

(22) Weiss G. What would you do? Dilemma #3: Pay for Performance: The noncompliance factor. Medical Economics. August 18, 2006.

Summary:

  • Brief case asking readers to vote on their preferred management of non-compliant patients under P4P.

Significance to Literature:

P4P can create moral dilemmas for clinicians treating non-compliant patients.

 

 

(24) O’Reilly KB. Quality Quandary. American Medical News. May 22/29, 2006.

Link: http://www.ama-assn.org/amednews/2006/05/22/prsa0522.htm

Summary:

  • Article defines process vs. outcome based P4P.
  • Expresses concerns for outcome based P4P.
  • Author stresses that doctors need to take control and hold themselves accountable.

Significance to Literature:

Expresses concerns that payers will usurp control of clinical care.

 

 

(30) Morriem HE. Result-Based Compensation in Health Care: A Good, but Limited, Idea. Journal of Law, Medicine & Ethics.2001: 29 174-181.

Link: http://www.allbusiness.com/legal/3586801-1.html

Summary:

  • Any system of compensation can be abused, or influence care.
  • Results based compensation does not ensure cost reduction, but can help quality.
  • Three primary limitations to outcome based compensation:
  • Surrogate markers not adequately validated.
  • Many factors cannot be measured, e.g. anxiety.
  • May encourage “cherry-picking” of patients

Significance to Literature:

Scholarly analysis of theoretical limitations of P4P

 

 

(40) Christianson JB, Knutson DJ, Mazze RS. Physician Pay-for-Performance: Implementation and Research Issues. Journal of General Internal Medicine. 2006: 21 S9-13.

PMID: 16637965

Summary:

  • Outlines many concerns regarding P4P
  • Specific concerns include:
    • Outcomes can be influenced by factors outside of the agents control
    • Rewarding a subset of choice measures presents many problems
    • Implementation costs
    • Centralization
    • Who is rewarded 
    • Transmission to the clinical levels
    • Mixed research direction
    • Unintended consequences
    • Overlapping programs
    • Changes over time

Significance to Literature:

Expresses concerns about P4P and calls for research while identifying high priority research areas in P4P.

 

 

***Key Article***

(66) Snyder L, Neubauer RL. Pay-for-Performance Principles That Promote Patient-Centered Care: An Ethics Manifesto. Annals of Internal Medicine. 2007: 127(11) 792-794.

PMID: 18056664

Summary:

  • A primary ethical concern within P4P is the unintentional adverse effect of decreasing access to unrewarded interventions.
  • Recommended action to offset adverse, avoidable effects:
    • Ensure transparency
    • Measure what is important to the patient
    • Monitor unwanted physician behavior and intervene
    • Measure continuity of care
    • Increase communication and increase access.

Significance to Literature:

P4P must take specific actions to avoid adverse effects.

 

 

(72) Dixon J, Chantler C, Billings J. Competition on Outcomes and Physician Leadership Are Not Enough to Reform Health Care. JAMA. 2007: 298(12) 1445-1447.

PMID: 17895462

Summary:

  • Financial bottom lines tend to drive healthcare reform.
  • Tinkering will not be enough to reform healthcare.
  • Huge physician leadership problem causing lack of directionality for healthcare reform.
  • This is a rebuttal to Porter and Teisberg’s 4 false solutions.

Significance to Literature:

Will P4P help change healthcare, is it enough.

 

 

***Key Article***

(79) P4P is changing me. Mansfield, Richard J. Medical Economics. May 4, 2007.

Link: http://medicaleconomics.modernmedicine.com/memag/Medical+Practice+Manage...

Summary:

  • Vermont Internist recounts case example in which P4P caused tension between clinician and patient.
  • Author questions whether clinicians will comply with P4P when benefits to patients are unclear.

Significance to Literature:

Rare published personal reports.

 

 

(96) Sheldon T. Dutch insurers pay midwives to refer fewer to hospital. British Medical Journal. 2006: 133, 1034.

Link: http://www.bmj.com/cgi/content/full/333/7577/1034-b

Summary:

  • Vast majority of deliveries in the Netherlands are done at home by midwives.
  • Insurers in the Netherlands offer midwives financial incentives for fewer hospital referrals.
  • The insurers hope to reduce caesarean sections, while obstetrician’s fear this will result in less quality care, and more missed complications.

Significance to Literature:

Example of potential adverse effects when insurers use financial incentives to cut cost.

 

 

(108) Hedgecoe AM. It’s money that matters: the financial context of ethical decision-making in modern biomedicine. Sociology of Health and Illness. 2006: 28(6) 768-784.

PMID: 17184417

Summary:

  • Examines current relationship of existing (non-P4P) financial constraints to patient and physician clinical decision making.
  • A sociological evaluation of the larger influences that determine the options available to clinicians and patients.
  • Author argues that financial influences on patient autonomy warrant further bioethical evaluation.

Significance to Literature:

Evidence that financial constraints on patients and clinicians already compromise patient autonomy. P4P may exacerbate this.

 

 

(113) Jones JW, McCullough LB, Richman, BW. Other people’s money: Ethics, finances, and bad outcomes. Journal of Vascular Surgery. 2006: 43 863-865.

PMID: 16616254

Summary:

  • The authors present a surgical case with a poor outcome, and highlight the financial costs to the widow.
  • Authors argue that a professional’s fees should not be based on outcome, comparing outcome-based reimbursement to contingency fees.
  • Authors assert that if surgeons operate on contingency, high-risk patients will be left without care.

Significance to Literature:

An argument against outcome-based reimbursement as contingency pay in surgical cases.

 

 

(150) Rose J. Industry Influence in the Creation of Pay-for-Performance Quality Measures. Quality Management in Health Care. 2008: 17(1) 27-34.

PMID: 18204375

Summary:

  • Article examines which organizations influence the standards for P4P; article identifies the NCQA and the AMA-PCPI. Author says we must examine their motives, and potential for industry influence.
  • Article cites examples where drug companies have influenced clinical practice guidelines (CPGs) in the past, and how that can be problematic.
  • Author argues that experts who set the CPGs should not have ties to drug companies.
  • Mentions using Britain’s NICE program as a model for the government to establish a board that creates CPGs not influenced by industry.

Significance to Literature:

Successful P4P relies on choosing measures unbiased by industry influence.

 

 

(159) Hayward RA, Kent DM. 6 EZ Steps to Improving Your Performance (or How to Make P4P Pay 4U!) JAMA. A Piece of Mind. 2008: 300(3) 255-256.

PMID: 18632535

Summary:

  • Authors satirically present 6 ways clinicians might game the P4P system for maximal reimbursement.
  • Argues that “Measuring ‘quality of care’ using arbitrary standards is difficult enough; measuring genuine quality of care is simply unrealistic.”

Significance to Literature:

Satire of P4P gaming reflects physician opposition to P4P.

 

 

(172) Larriviere DG, Bernat JL. Threats to physician autonomy in a performance-based reimbursement system. Neurology. 2008: 70 2338-2342.

PMID: 18541888

Summary:

  • Any performance metric reimbursement system must include:
    • Clinical practice guidelines (CPGs) must be based on patient outcomes and be produced by expert medical societies.
    • Must allow physicians to appropriately depart from CPGs.
    • CPGs must be able to respond to new evidence.

Significance to Literature:

Physician autonomy must be maintained when performance metrics are implemented.

 

 

(214) Mangin D, Toop L. The Quality and Outcomes Framework: what have you done to yourselves? British Journal of General Practice. Editorials. 2007: 435-437.

PMID: 17550665

Summary:

  • Authors argue that the QOF has begun to de-professionalize doctors, and sent the message that QOF priorities are the most important aspects of care, shifting the focus from “patient-centred” care.
  • There was evidence that quality was improving before the QOF, but now it appears to the public that quality improvement was the result of financial reward.
  • Authors advocate for a “system which promotes evidence-informed care supported by a professional education system which uses evidence and feedback, guidance not guidelines, and provides options (with attendant uncertainties) for GP’s and patients to interpret for themselves.“

Significance to Literature:

Argument that QOF incentives (P4P) have resulted in de-professionalization and non-patient centered care.

 

 

(217) Plested III WG. Fair pay a sounder approach than “pay for quality.” American Medical News. Opinion. March 1, 2004.

Link: http://www.ama-assn.org/amednews/2004/03/01/edca0301.htm

Summary:

  • Author states “Every physician knows that he or she would not even consider practicing anything but the best or highest quality of medicine possible.”
  • Author believes in the long run that P4P is “simply a way to reduce payments to the vast majority of physicians.”
  • Physicians must resist the notion that demanding fair reimbursement is “self-serving,” and accept that it is a reality required to sustain our profession.

Significance to Literature:

Offers a criticism of the insidious use of P4P by insurers as a cost control mechanism.

 

 

(228) Jauhar S. The Pitfalls of Linking Doctors’ Pay to Performance. The New York Times. September 9, 2008.

Link: http://www.nytimes.com/2008/09/09/health/09essa.html?_r=1&ei=5070&emc=et...

Summary:

  • P4P will have unintended consequences that must be addressed, especially pertaining to Medicare beneficiaries that have multiple chronic conditions.
  • “Doctors who wrote guidelines never expected them to become performance measures.”

Significance to Literature:

Article informs the general public that P4P will have unintended consequences.

 

 

(232) Weiss GG. What would you do? P4P and noncompliance. Medical Economics. December 15, 2006.

Summary:

  • Article offers two scenarios about non-compliant patients and then asks physicians if they would discharge either of the patients. 77% said they would discharge neither, but physicians that would or would not discharge offered much resentment towards this issue because of P4P.
  • A brief section of physician quotes/opinions is offered in the article.

Significance to Literature:

Many physicians are unhappy that P4P has the potential to raise so many ethical issues.


 

(246) Fanestil BD. The Tyranny of the Measuring Cup. JAMA. 2009: 301(15) 1515-1516.

PMID: 19366762

Summary:

  • "The 'art' [of medicine] is difficult to measure, and we need to be careful to not let ourselves become tyrannized by the measuring cup."

Significance to Literature:

Cautions physicians against cookbook medicine.

 

 

(256) Eikens J. Performance Anxiety. Minnesota Medicine. February 2007.

PMID: 17388257

Summary:

  • Personal testimony of physician potentially being persuaded to treat a patient solely based on a P4P bonus.
  • Author questions who he is really working for, himself, his organization, the insurance company, or his patient?

Significance to Literature:

Personal account of a potential P4P burden (non-patient centered care).

 

 

(274) Ellwing S. Pay for Performance: A Physician’s Guide to Evaluating Incentive Plans. Metro Doctors. September/October, 2005.

Summary:

  • Contains a series of questions that address 5 primary P4P issues physicians should ask when evaluating P4P programs.
  • Issues include quality metrics, patient access, physician participation, data collection, and program design.

Significance to Literature:

AMA brochure for physicians to critically analyze P4P programs.


 

(279) McDonald R, Roland M. Pay for Performance in Primary Care in England and California: Comparison of Unintended Consequences. Annals of Family Medicine. 2009: 7(2) 121-127.

PMID: 19273866

Summary:

  • Results of interviewing 20 Primary Care Physicians (PCPs) in California compared with 20 English PCPs, specifically analyzing unintended consequences of P4P programs.
  • Three major themes of unintended consequences emerged from the interviews:
    • "Changes in the nature of the office visit."
    • "Threats to physician-patient relationship."
    • "Threats to professional autonmy."
  • PCPs in California generally expressed much less satisfaction with P4P than their English counterparts.
  • In California, many PCPs were "unaware of specific targets or had poor understanding of the relationship between performance and incentives."

Significance to Literature:

Unintended consequences vary greatly due to P4P program design features.

 

 

(333) Sandler M. Going Up: Surge in Exec Comp Driven by Pay-for Performance. Modern Healthcare. 2015 Aug 10;45(32): 18-22.

PMID: 26642550

Summary:

  • Many top officials of our nation’s hospital systems received large pay increases in 2015, likely the result of bonus packages tied to improved quality and financial performance.
  • An increasing number of health care systems are utilizing performance-based pay for top executives and aligning payment with hospital quality goals.
  • Executive salaries are rising at a higher rate as compared to other personnel and segments of healthcare.

Significance to Literature:

While top hospitals executives aren’t exempt from having their payment tied to their hospitals’ clinical quality, this has resulted in a wider gap between executive and others’ compensation.

 

***Key Article***

(360) Dorsey ER, Ritzer G. The McDonaldization of Medicine. JAMA Neurology. 2016 Jan 1; 73(1): 15-6. doi: 10.1001/jamaneurol.2015.3449.

PMID: 265696

Summary:

  • “Viewpont” article, criticizes elements of modern medical practice which parallel the four basic principles of McDonaldization - efficiency, calculability, predictability, and control:
    • Efficiency: Less expensive and skilled clinicians often hired to reduce visit time with patients
    • Calculability: The care patients receive is increasingly based on the overall cost to the system
    • Predictability: Scripted histories, excessive checklists, and uniform patient visit lengths
    • Control - Patient-physician dialogue is determined increasingly by what the electronic medical record requires
  • McDonaldization can dehumanize the doctor-patient relationship and “replaces energy and empathy with fatigue and inertia in residents and burnout in physicians”

Significance to Literature:

Authors’ “Viewpoint” article cautions “McDonaldization results in unreasonable systems that deny the humanity, the human reason, of the people who work within them or are served by them.”

 

***Key Article***

(369) Roland M. Should doctors be able to exclude patients from pay-for-performance schemes? BMJ Qual Saf. 2015 Dec 30. pii: bmjqs-2015-005003. doi: 10.1136/bmjqs-2015-005003. [Epub ahead of print]

PMID: 26717988

Summary:

  • United Kingdom’s pay-for-performance program, Quality and Outcomes Framework, allows for general practitioners to exclude patients from quality calculations without financial penalty
  • This practice, known as exception reporting, was designed to allow providers to use clinical judgement to exempt patients from evidence-based guidelines when not applicable and protect physicians from patient non-compliance, but has been controversial.
  • Notable points include:
    • 1% of practices were responsible for 15% of all exception reporting
    • Higher target quality markers are associated with higher rates of exception reporting
    • Increased exception reporting for complex patients with multiple comorbidities
    • Patients from lower socioeconomic areas are more likely to be exception reported
    • Exception reporting is associated with increased risk of death for patients

Significance to Literature:

Physicians exception reported uncommonly yet more work needs to be done to better understand if and when providers’ decisions to circumvent evidence-based guidelines is appropriate.

 

(378) Epstein AM, Jha AK, Orvav EJ. The Impact of Pay-for-Performance on Quality of Care for Minority Patients. Am J Manag Care. 2014 Oct 1;20(10):e479-86.

PMID: 25414986

Summary:

  • Retrospective cohort study comparing racial disparities in process quality and outcomes from 2004-2008 in hospitals participating in the Premier Hospital Quality Incentive Demonstration versus control hospitals
  • Patient-level Hospital Quality Alliance (HQA) data indicated the following:
  • Originally, black patients had lower performance on process quality measures, but the difference decreased after P4P implementation in both Premier (those with P4P) and non-Premier hospitals
  • Mortality decreased for black patients in comparison to whites in both Premier and non-Premier hospitals
  • Greater disparity reduction was shown in Premier hospitals with process quality measures and mortality for patients with acute myocardial infarction or congestive heart failure, respectively

Significance to Literature:

Evidence opposing the concern that P4P would result in lower quality of care for hospitalized minority patients

 

*Key Article*

(420) Lin et al. Impact of pay for performance on behavior of primary care physicians and patient outcomes. J Evid Based Med. 2015 Dec 12. doi: 10.1111/jebm.12185. [Epub ahead of print].

PMID: 26667492

Summary:

  • Systematic review of 44 studies to assess the impact of P4P on primary care physician behavior and patient outcomes
  • Overall positive effect was found for the management of disease although process outcomes often improved more than endpoint outcomes
  • Baseline quality of medical care and the size of practice both limit performance improvement
  • Unintended consequences associated with P4P were found to include:
    • Rising medical costs for programs without financial metrics
    • Inconsistent effects on health equity - some programs improved and some programs exacerbated inequities related to sex, age, ethnicity, socioeconomic status, comorbidity/severity, duration of illness, and size of practice.
    • Inconsistency in patient satisfaction (some increased and some decreased patient satisfaction)

Significance to Literature:

Evidence for P4P has shown positive clinical effects for most diseases, but implementation may bring about negative unintended consequences, particularly related to health equity.

 

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