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 that challenge physicians and cause them to make poor choices. Many authors (24, 30, 113, 228, 232, 274, 279) 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 (66, 108, 150). 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 it is commonly associated with risk adjustment (see Disparities and Risk Adjustment section).
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 for or evolve when evidence conflicts with 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.