In the not-too-distant future, a multiphysician hospitalist group is a participant in a pay-for-performance (P4P) program. Dr. Buchmann, the group’s lead hospitalist, is confronted by his hospital’s administration and informed that his doctors are performing below regional benchmarks for standards of care for community-acquired pneumonia, and, in fact, the hospital as a whole is below the mean performance levels.
The hospital threatens to break its contract with Dr. Buchmann’s group despite his response that his group sees a far more complex population than these standards can account for—and besides, his group has implemented a number of important quality initiatives in other diseases that are not part of the P4P program.
Several of the group’s hospitalists state that they will stop seeing indigent patients and will no longer take referrals for high-risk patients. Another partner feels it is unethical to continue treating pneumonia patients at the hospital without informing them of these quality findings and at least offering the option of transfer to a facility with better scores. Dr. Buchmann finds all these propositions unsettling.
While these physicians’ responses may sound extreme, the behavior of physicians caught between the hammer of financial survival and the anvil of professional ethics is unpredictable. Medicare and other payers have been implementing P4P plans as the latest attempt to stimulate quality reform. There are dozens of P4P-based programs operating in the United States, and the financial implications are daunting. Further, P4P is taking hold despite a relative paucity of research regarding its effectiveness in improving outcomes.
The underlying rationale of P4P is the use of economic incentives to stimulate changes in provider behavior. Recent work from the RAND Corporation suggests that as much as one-half of healthcare is not based on “accepted” best practices.1 And with increasing attention on the role of errors in medical practice, any effort to improve care seems, on its surface, laudable.
In general, key elements of P4P programs include a set of performance measures, the collection of data, comparison of provider data with benchmarks, and rewards for physicians who meet or exceed those targets. The interface between economic and financial incentives requires physicians to ensure that their behavior is in line with ethical and professional standards. While journals of medicine, law, and business contain many articles devoted to the policy and market implications of P4P, there is surprisingly little discussion in the literature regarding the potential ethical challenges that physicians may face in these programs.
For hospitalists (and other physicians), P4P may present several troubling ethical issues. Because the current scope of P4P is limited to a few diseases, widespread implementation might lead to relative neglect of patients with other illnesses. Higher-risk patients might be avoided, and individual patient concerns might become subjugated to population performance measures. Hospitalists could face the additional conflict of being accountable to (and/or dependent upon) hospitals, which feel P4P pressures of their own. A final issue is the question of whether shared decision-making and patient-centered care mandate disclosure of non-public quality data to patients.
The American Medical Association (AMA) has a policy that specifically addresses P4P.2 Its “Pay-for-Performance Principles and Guidelines” call for physician participation in P4P to be voluntary and to allow physicians to access their ratings for potential appeal prior to wider release. The policy insists that quality of care be paramount over cost savings and that the physician-patient relationship be preserved. Of course, P4P programs may not share the AMA’s ethical concerns and are not bound to consider them.