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:

  • Ethical interactions encompass honesty with patients, maintaining the confidentiality of patient information, avoiding improper relationships that take advantage of the patient's vulnerability and avoiding conflicts of interest. Transparency of quality measurement and disclosure of payment incentives may enhance patient trust. The point of P4P programs is to create a financial incentive that aligns the interests of physicians and patients, and this can often motivate both increased use of preventive services and improved care management.
  • Medical professionalism envisions an equal standard of care for all patients. Pay-for-performance programs are unlikely to foster the equitable distribution of care unless they include measures of access to care and adequate case-mix and risk adjustment strategies. Measuring variability in the allocation of patients among providers enables adjustment of scoring and performance rewards based on the complexity of patient socioeconomic and clinical case-mix of a provider group.
  • P4P programs that pay only on the basis of the top tier of performance put physicians in competition with each other. P4P programs could be designed to encourage the sharing of knowledge, scientific evidence and information – a principle of professionalism.