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Pay for Performance: Will It Make a Difference?
Written by Ardena L. Flippin, MD, MBA   
Dr. Ardena Flippin

The intent of Pay-for-Performance (P4P) seems to be payment to encourage certain behaviors.  I think that the majority of physicians practice good medicine and have adapted to the behavioral demands of increased documentation of what we ordinarily do as medical caretakers. Is documenting services rendered documenting health?

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Various reasons for increased interest in P4P in the United States are: 
  • Institute of Medicine Spotlights Quality ad Safety problems
  • Employers’ rising health insurance costs
  • The national health care crisis 
  • Medicare budget pressure
  • Improvement in information technology, e.g., EMR, HIPAA transactional standards 

(Pay for Performance in the United States Health Care System: An Overview and Recent Findings from the Community Tracking Study)

Is a carrot and stick approach making a difference in how physicians do their jobs? And is this approach benefiting providers and/or patients’ health? A colleague suggested that P4P might help bad doctors improve their performance and practice better medicine. Many of the physicians I know are less than enthusiastic about P4P, and maybe it’s too early to tell if it will have a positive effect on quality of care and ultimately produce and/or effect system(s) reform. In a study reported in JAMA, “the pay-for-performance program was not associated with a significant incremental improvement in quality of care or outcomes for acute myocardial infarction…we did not find evidence that pay for performance had an adverse association with improvement in processes of care that were not subject to financial incentives.” (Pay for Performance, Quality of Care, and Outcomes in Acute Myocardial infarction. JAMA, Vol. 297 No. 21, June 6, 2007)

The lexicon of P4P includes concepts and terms such as incentives, cost efficiency, information technology and patient satisfaction. One word that doesn’t appear in this lexicon is “communication”, and an interesting example of the lack of communication in the P4P concept is described in another JAMA article. In this article “a large percentage of surveyed executives reported that they examine health plan quality data, but few reported using it for performance rewards or to influence employees. Physician quality information is even less commonly examined or used by employers to reward performance or influence employee choice of providers.” (Employers’ Use of Value-Based Purchasing Strategies. JAMA, November 21, 2007. Vol. 298, No. 19). This is an example of how communication can affect “health”, and access to quality healthcare, and this communication didn’t happen.

I think that in spite of behavioral change, the current generation of physicians has practiced medicine absent the consuming incentive of “mo money”, and concerned themselves primarily with practicing good medicine.

So when we receive financial “credit” for services rendered measured by thresholds, targets, statistics and bonuses, the question still remains – do services rendered equal “health”?


Pay-for-Performance in the United States Health Care System: An overview and Recent Findings from the Community Tracking Study. 

Pay for Performance, Quality of Care, and Outcomes in Acute Myocardial infarction. JAMA, Vol. 297 No. 21, June 6, 2007

Physician Pay-for-Performance Programs Taking Hold. NEJM Career Center. December 2007

About the Author

Dr. Flippin brings a wealth of experience, starting with her long tenure as an attending physician at the Cook County Hospital Emergency Department. She is currently Corporate Compliance and HIPAA Privacy Officer at major Chicago hospital.


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