Pay-for-performance programs stir debate

Ethics Forum. Nov. 6, 2006.

Scenario: Is pay-for-performance a viable way to improve patient care and safety?

Many health care organizations are instituting pay-for-performance measures, in part because of cost-containment motives. A physician who signs on to such a program may find ethical conflicts between patients' interests and his or her own financial benefit.

Reply:

The American Medical Association's position on pay-for-performance (P4P) programs is defined in two recent reports, one from the AMA Board of Trustees and one from the AMA's Council on Ethical and Judicial Affairs. These reports describe boundaries within which P4P designers must create their plans and spell out the ethical obligations of physicians who participate in them.

The board report stipulates, for example, that such programs must improve quality of care by means of evidence-based measures and must permit variations in individual patient care based on clinical judgment. Valid analytical methods should be used in assessing physician performance, and physicians should be allowed to review, comment upon and appeal results of those analyses.

The CEJA report warns against a variety of conflicts of interest that could undermine patient care and specifies ethical guidelines for physicians in administrative positions and for those in practice. Physician executives who design or implement P4P programs should ensure that incentives are intended and structured primarily to promote quality of care and safety of patients. Cost containment should be neither a primary driver of policy, nor the primary goal of such programs. If too heavily emphasized, cost containment can be inimical to quality care and patient safety. Not only should built-in flexibility allow physicians to accommodate varying needs of individual patients, but performance measures also should be adjusted by risk stratification and case mix to ensure that physicians are not encouraged to avoid high-risk individuals and populations.