Ethical Issues

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Numerous ethical and moral issues surround P4P. This section provides just an overview of the numerous existing issues. We have also devoted a section to pragmatic challenges to P4P, see below. Satin (26) not only provides a brief overview of P4P’s ethical issues, but suggests that bioethicists should play a central role in P4P research and policy. Jones (88) shows that physicians change practice patterns based on reimbursement, and Relman (97) questions whether market forces move P4P in a morally acceptable manner.

     Goold, amongst others, (68130166265271) question the potential adverse effects of P4P on the doctor-patient relationship. Campbell (162) surveys English family doctors and nurses regarding P4P and the doctor-patient relationship, demonstrating that many believe P4P has negatively affected this relationship.

      Ethical analysis in terms of benefits and burdens is common among bioethicists. Most of the current medical literature investigates the burdens of P4P. Occasionally, authors acknowledge the potential benefits such as quality improvement or cost savings. In stark contrast, much of the corporate, economics, and management literature focuses on the benefits of P4P (search databases such as Business Search Premier (381 results) and EconLit, Sociological Abstracts, and PAIS International (20 results) herein not included). Indeed, one could interpret each positive P4P trial as a “benefit” in the ethical debate about P4P. The ethical benefits were few and far between throughout the literature. We believe that the absence of any substantial discussion about the moral benefits of P4P suggests a need for research in this area.

     Many authors, including Rosenthal (196) encourage ongoing research on ethical issues in P4P, most notably the impact of P4P on medical professionalism. Most agree that early critical analysis of P4P may prevent moral controversy.

 

Ethical Issues Literature

 

(6) Goold, SD. Money and Trust: Relationships between Patients, Physicians, and Health Plans. Journal of Health Policy and Law. 1998:23(4) 687-695.

Link: http://jhppl.dukejournals.org/cgi/content/abstract/23/4/687

Summary:

  • Calls for evaluation of the effect of financial reimbursement systems for physicians on doctor-patient and organization-member trust.
  • Author believes “regulation of physician incentives systems may be better accomplished on a national level.”

Significance to Literature:

To what extent will P4P alter relationships between patients, physicians, and health plans.

 

 

(8) Goold S. Trust and Physician Payment: The ways in which your physicians are paid can affect patient trust. Healthcare Executive. July/Aug 1998.

Summary:

  • All payment forms to physicians can influence care.
  • New payment systems must scrutinize influence on patient trust.
  • Author presents sample ethical conflicts.

Significance to Literature:

Patient trust must be considered during implementation of P4P.

 

 

(26) Satin DJ. The Impact of Pay-for-Performance Beyond Quality Markers-A Call for Bioethics Research. Bioethics Examiner. University of Minnesota Center for Bioethics. Fall 2006: 10(1) 1-3.

Summary:

  • Author lays out proposed research program for unanticipated consequences or safety profile of P4P.
  • Suggests bioethics and bioethicists should play a central role in interdisciplinary P4P research.

Significance to Literature:

Outlines key research questions regarding unanticipated consequences or safety of P4P.

 

 

(37) Sade RM, Blum E. Pay-for-Performance programs in debate. American Medical News. November 6, 2006.

Link: http://www.ama-assn.org/amednews/2006/11/06/prcb1106.htm

Summary:

  • Two editorials expressing moral concerns about P4P.
  • First editorial argues that goals must not be cost containment.
  • Second, provides three premises why P4P will not work:
    • 1) P4P is not statistically valid.
    • 2) P4P denies the root cause of poor healthcare.
    • 3) P4P is inconsistent with medical ethics.

Significance to Literature:

Expresses moral concerns of physicians regarding P4P.

 

 

(88) Jones JW, McCullough LB, Richman, BW. Show me the money: The ethics of physicians’ income. Journal of Vascular Surgery. 2005; 42:377-379.

PMID: 16102645

Summary:

  • Outlines some of the current options physicians can take to increase income.
  • Provides statistics to show that physicians change practice patterns in response to changes in reimbursement.
  • States various ethical issues involved with physician compensation

Significance to Literature:

Physicians change practice patterns in response to changes in reimbursement.

 

 

(97) Relman AS. Medical Professionalism in a Commercialized Health Care Market. JAMA. Commentary. 2007: 298(22), 2668-2670.

PMID: 18073363

Summary:

  • Insurers, the law, and pharmaceutical corporations have all played a role in the decline on medical professionalism.
  • American medical professions should resist commercialization.

Significance to Literature:

Market forces are not moral entities.

 

 

(130) Beran MS, Collision Course? HDHP’s, P4P incentives and the patient-physician relationship. Minnesota Physician. 2007: 21(8).

Summary:

  • Park Nicollet Institute sought to look at the Physician patient relationship in patients with high deductibles and physicians enrolled in P4P programs.
  • They found that financial incentives are not discussed with patients.
  • Patients feel uncomfortable with their physicians receiving financial incentives based on aspects of care for which the patients feel responsible (e.g. hgbA1c levels.)
  • Physicians are concerned about “cherry picking” for good patients, and incentives may hurt the physician-physician relationship if rewards distributed to individual physicians.

Significance to Literature:

Documented interviews of patients and physicians worries about the effect P4P on relationships.

 

 

***Key Article***

(162) Campbell SM, McDonald R, Lester H. The Experience of Pay for Performance in English Family Practice: A Qualitative Study. Annals of Family Medicine. 2008: 6(3) 228-234.

PMID: 18474885

Summary:

  • Interviewed 20 nurses and 21 family doctors across England to explore beliefs and concerns about changes to service as a result of P4P between 2004-2007.
  • Many doctors and nurses acknowledged that nurses have become the primary provider of health care for patients with chronic disease, however most P4P reimbursements go to doctors.
  • The QOF achieved objectives:
    • Improved disease specific processes of patient care
    • Increased primary care physician income
    • Improved data capture
  • Lists unintended consequences including:
    • Dual QOF-patient agenda within consultations
    • Potential deskilling of doctors
    • Decline in doctor/patient continuity of care
    • Resentment by team member not benefiting financially
    • Concerns about an ongoing culture of performance monitoring

Significance to Literature:

British family doctors and nurses surveyed believe that despite benefits, P4P negatively affects relationships between doctors, nurses, and patients.

 

 

(166) Grosso M. Patient safety, quality of care, and physician professionalism: Do these goals conflict? The Journal of Family Practice: Current Clinical Practice. June 2008 S17-S19.

Summary:

  • Author begins with a story about teaching residents about quality measurements and errors in medicine.
  • “Linking a system-based perspective with the traditional professional psyche calls for a major frame shift.”

Significance to Literature:

Questions if a systems-based approach to health care (i.e. P4P) conflicts with traditional concepts of professionalism within a doctor-patient relationship.

 

 

(196) Rosenthal MB, Frank RG. What is the Empirical Basis for Paying for Quality in Health Care. Medical Care and Research Review. 2006: 63(135) 135-157.

PMID: 16595409

Summary:

  • Article highlights findings from health services research and several other fields about the evidence of performance-based incentives.
  • Authors discuss the key differences between health care and other fields, highlighting the professionalism aspect and the physician-patient relationship.
  • Analysis of research from performance-based incentives in executive compensation, teachers, job training, and psychology.
  • The empirical evidence supporting P4P in health care and other industries is rather weak. Also, the evidence regarding unintended consequences of P4P outside of health care is well established that it exists.
  • Risk adjustment was often a needed part of P4P in other fields.
  • Also, gaming was sited as a common misuse of P4P.

Significance to Literature:

“Research must focus on whether paying for quality is cost-effective compared to other quality improvement interventions.”



(236) Satin DJ. A Conversation With David Satin M.D. Colleague Interview Metro Doctors. September/October 2008.

Link: http://www.ehcca.com/presentations/hcii1/1_06.pdf

Summary:

  • Family physician/ethicist answers questions about P4P.
  • Recommends against any metrics of ethical clinician behavior.
  • Recommends against public reporting of individual clinician performance rather than aggregate practice performance.
  • Defends the concept of risk-adjusted efficiency measures that truly measure cost/outcome.

Significance to Literature:

Clinician/ethicist examines controversial issues surrounding P4P in 2008.


 

(265) Barry CA, Bradley CP, Britten N, Stevenson FA, Barber N. Patients’ unvoiced agendas in general practice consultations: qualitative study. British Medical Journal. 2000: 320 1246-1250.

PMID: 10797036

Summary:

  • Patient agendas are often complex and difficult to address when needs are not voiced by the patient.

Significance to Literature:

Patient agendas may compete with P4P measures for physicians attention and may go unaddressed if not clearly voiced. P4P may compete with patient-centered care.


 

(271) Eikens J, Lenarz L. Pay for Performance’: two views. SCOPE. 2007: 12(2) 1,6.

Link: http://related:fvstage.fairview.org/fairview/fv/groups/Internet/@Communi...

Summary:

  • Dr. Eikens offers a personal anecdote about the temptations and difficulties surrounding P4P.
  • Dr. Lenarz provides a counter point arguing for quality based reimbursement rather than quantity alone. 

Significance to Literature:

P4P programs must have a delicately balance competing interests to be effective and maintain the physician-patient relationship.

 

(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’ “Viewpont” 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.

 

(437) Zweifel P, Janus K. Medical ethics: enhanced or undermined by modes of payment? Eur J Health Econ. 2016 Apr 12. [Epub ahead of print]

PMID: 27072055

Summary:

  • Two theoretical models of behavior were created to test whether changing from fee-for-service (FFS) to prospective payment (PP) or P4P jeopardizes medical ethics or patient well-being
    • Transitions were analyzed both in solo practice and in a hospital or group practice
  • In both practice types, FFS to PP was associated with undermining of medical ethics while FFS to P4P transition was correlated with an enhancement in the relative importance of patient well-being
    • "Provided that P4P payment is tied to improvement in patient health to a sufficiently high degree”
  • Four case studies included provide some evidence for these predictions

Significance to Literature:

Attempt to evaluate empirical moral differences in transitions between payment models.

 

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