A Doctor’s “Pay For Performance” Anxiety

The debate over paying physicians for performance is a fascinating one with many unspoken (and often unconscious) overtones. With my social science background, I’m probably overly inclined to believe it can work. I’ve had to learn the barriers and ‘right-size’ my expectations. Physicians, with their ingrained self-confidence, tend to be overly resistant. The truth, I suspect, is somewhere in the middle.

This piece is worth reading as a smart, concise, and articulate summary of a contrarian position of “pay for performance” metrics and bonuses in healthcare. It’s written by Richard Reece, MD, a Minnesota physician who objects to P4P on the following grounds:

• Patient behavior is a major influence on medical outcomes.
• There are 2,000 guidelines out there, which only confuses and overwhelms doctors. Which should be followed? How is it practical?
• Hospital care may work under a P4P model, but it won’t work in the physician setting.
• Surgeries and technologies don’t eliminate the etiology, so medical interventions can’t be measured under a model that punishes them for recurrence.
• The sedentary nature of modern society propagates illness.

Dr. Reece’s piece (no pun intended there) is well worth reading. His objections are valid. Still, I don’t believe he poses any insurmountable obstacles to physician-oriented P4P, especially if measurements focus on those factors a physician can control.

Dr. Reece himself points out that physicians “only follow preventive and treatment guidelines 50 percent to 55 percent of the time.” He adds that “doctors could do a much better job communicating with and educating patients, deploying the Internet (for example) to reach patients when they are outside of the immediate care setting.”

Great. He’s just identified two measurement points for physician P4P. It is difficult to measure physician performance, for reasons Dr. Reece describes well. But it still can be done. Dr. Reece shows us two highly workable performance indicators. Nevertheless, he concludes it’s a bad and unworkable idea.

As I say, it’s a fascinating debate with many unspoken overtones.