Programs, Health Quality Can Co-Exist, Panel
Tossing aside concerns about professionalism and
payments, an expert panel convened by the American College of
Physicians (ACP) said that properly designed P4P programs can
strengthen the relationship between physicians and patients and
increase the likelihood that physicians will deliver the best possible
care. The panel’s analysis appears in the
Annals of Internal Medicine.
"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
- Application of scientific evidence to deliver
and improve care.
- Ethically appropriate interactions between
physicians and patients.
- Promoting equity in healthcare delivery.
- Commitment to the profession and its members.
By systematically considering the potential
interactions between P4P and each of the themes, the panel concluded
- 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. P4P 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
- 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
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