P4P models could improve medical professionalism

Properly designed pay-for-performance programs can strengthen the relationship between physicians and patients and increase the likelihood that physicians will deliver the best possible care, according to a panel convened by the American College of Physicians.

"Concerns about the conflicts between medical professionalism and pay-for-performance have been based primarily on theories about the tension between external motivation and self-interest and the internal motivation and self-restraint that characterize professional expectations," said panel member Amir Qaseem, a senior medical associate with the ACP.

"We believe that physicians should play a key role in defining and evaluating P4P programs that are compatible with professionalism,” he said.

The ACP-led panel of experts in clinical medicine, law, management and health policy met six times to examine the relationship between medical professionalism and P4P incentive programs.

Using the Charter on Medical Professionalism developed by the ACP Foundation, American Board of Internal Medicine Foundation and European Federation of Internal Medicine, the panel organized the charter's 10 professional responsibilities around four themes especially pertinent to P4P:

  • Application of scientific evidence to deliver and improve care;
  • Ethically appropriate interactions between physicians and patients;
  • Promoting equity in healthcare delivery; and
  • Commitment to the profession and its members.

According to the ACP, the panel believes that medical professionalism “rests on the integrity of scientific standards grounded in research evidence and the translation of evidence into practice guidelines, which define the proper use and implementation of diagnostic testing and therapeutics.”

A P4P incentive should be linked to carefully specified, evidence-based measures of the process of care because they can drive the delivery of care to conform to scientific evidence, according to the panel. Inadequately risk-adjusted measures that don't recognize the severity or complexity of a patient's condition may lead physicians to avoid patients with severe or complex illness.

The panel also concluded that:

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