Properly designed pay-for-performance models can support medical professionalism

"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, MD, PhD, MHA, FACP, a senior medical associate with ACP. "We believe that physicians should play a key role in defining and evaluating P4P programs that are compatible with professionalism."

The ACP-led panel of experts in clinical medicine, law, management, and health policy met six times to examine the relationship between medical professionalism (a code of conduct that under ideal circumstances is adhered to by all professionals) and P4P incentive programs (various financial incentive programs that differ in eligibility requirements, selection and scope of measures, formula for determining payment, and magnitude of payments).

Using the Charter on Medical Professionalism -- developed by the ACP Foundation, American Board of Internal Medicine Foundation, and European Federation of Internal Medicine -- as a framework, 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 health care delivery
• commitment to the profession and its members

By systematically considering the potential interactions between P4P and each of the themes, the panel concluded the following:

• 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 such measures can drive the delivery of care to conform to scientific evidence. Inadequately risk-adjusted measures that do not recognize the severity or complexity of a patient's condition may lead physicians to avoid patients with severe or complex illness (cherry picking). The scientific evidence must be protected from inappropriate influence by nonprofessionals or others who have a direct financial interest in a particular definition of a standard or guideline or in a performance measure based on one.
• 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.
• Pay-for-performance 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.

The American College of Physicians position paper is titled Pay-for-Performance Principles that Ensure the Promotion of Patient Centered Care.