'Deep flaws' with pay-for-performance model need to be addressed to provide quality health care, according to commentary

The "general intent" of pay-for-performance programs "is to reward doctors for providing better care," but as they gain "momentum, the initiative[s] may be having untoward consequences," Sandeep Jauhar, a New York-based cardiologist and author, writes in a New York Times commentary. "To get an inkling of the potential problems," Jauhar discusses another quality-improvement program: surgical report cards.

The program, which was introduced in the early 1990s, was intended "to improve the quality of cardiac surgery by pointing out deficiencies in hospitals and surgeons; those who did not measure up would be forced to improve," according to Jauhar. However, studies on the program "demonstrated there was a significant amount of 'cherry-picking' of patients in states with mandatory report cards," Jauhar writes. "With surgical report cards, surgeons' numbers improved not only because of better performance but also because dying patients were not getting the operations they needed," he writes, adding, "Pay for performance is likely to have similar repercussions."

According to Jauhar, "Under [pay for performance], there is pressure to treat even when the diagnosis isn't firm." The "incentives for physicians raise problems, too," he writes. He notes that physicians are "being encouraged to voluntarily report to Medicare on 16 quality indicators, including prescribing aspirin and beta blocker drugs to patients who have suffered heart attacks and strict cholesterol and blood pressure control for diabetics." He continues, "Those who perform well receive cash bonuses," but "many doctors have expressed concern that they will feel pressured to prescribe 'mandated' drugs, even to elderly patients who may not benefit, and to cherry-pick patients who can comply with pay-for-performance measures."

Jauhar writes, "Care is widely dispersed, so it is difficult to assign responsibility to one doctor," so if "a doctor assumes responsibility for only a minority of her patients, then there is little financial incentive to participate in [pay for performance]" and if "she assumes too much responsibility, she may be unfairly blamed for any lapses in quality."

Jauhar notes that it is not "clear that pay for performance will actually result in better care, because it may end up benefiting mainly those physicians who already meet the guidelines," asking, "If they can collect bonuses by maintaining the status quo, what is the incentive to improve?" Physicians "have seldom been rewarded for excellence, at least not in any tangible way," he writes. "At first glance, pay for performance would seem to remedy this problem," but "first its deep flaws must be addressed before patient care is compromised in unexpected ways," he concludes (Jauhar, New York Times, 9/9).