Pay for Performance (P4P): Will This Drive Better Outcomes for Kidney Patients?

A recent editorial in the New York Times described a move by the New York City public hospital system to “pay doctors based on how well they perform.” (1) Under this program, the more than 3,000 salaried doctors at the NYU School of Medicine, the Mount Sinai School of Medicine and the Physician Affiliate Group of New York will receive no cost-of-living increases for the next three years, but there will be annual bonuses tied to meeting quality-performance goals. In the same issue of the Times there is an important critique of the pay-for-performance (P4P) approach, describing what many policy experts have said for years: “If only it worked.” (2) Op-ed columnist Bill Keller points out that the real driver of costs in our healthcare system is not overutilization of services, but rather the high unit cost of each service. Others may debate this premise, but the reality is likely a bit of both—more units and higher cost for each. As Bill Clinton said during the 2012 Democratic National Convention, “it’s math, folks,” and P4P is unlikely to change these factors significantly.

Rather than speculate on whether P4P is effective in changing physician behavior, improving quality and controlling costs, what can we learn from studies? Houle and colleagues from Canada recently published an exhaustive systematic review of this topic. (3) Unfortunately, their work showed that the number of rigorous, evaluable programs was quite small, making it difficult to draw firm conclusions on the effectiveness of P4P. Others have commented that “evaluation of pay for performance initiatives has not kept pace with the rush to implement them….” (4) Houle et al conclude, “Although P4P seems to be useful in business settings and may serve as a means to signal which elements of care are valued within a participating health care organization, the current evidence for P4P targeting individual practitioners is insufficient to recommend wholesale adoption in health care systems at this time.”

That brings us back to the beginning: how can nephrologists continue to be motivated to drive higher quality for kidney patients while controlling the overall costs of care? Certainly P4P, if appropriately constructed (meaningful, actionable metrics; significant payments for quality; full transparency and other requirements) can play a role, but experience suggests that such programs are generally not designed to optimize impact. Johns Hopkins professor Peter Pronovost, the guru behind eliminating catheter-associated bloodstream infections (CABSI), suggests that driving better quality should not require “bribing” doctors, but rather playing to doctors’ professionalism. Is this just pie-in-the-sky thinking?

We have a case study in nephrology that makes Pronovost’s point. The Renal Physicians Association put together a task force several years ago to look at CKD care. (5)  In collaboration with investigators at Duke University, data from nearly 2,000 CKD patients was analyzed through chart reviews to see how well nephrologists and non-nephrologists adhered to available clinical practice guidelines in this area. Although nephrologists performed better than non-nephrologists, neither group’s performance was stellar. Participating nephrologists were provided the results of the study, and repeat chart reviews were conducted six months later. Results improved dramatically. (6) The only incentive was seeing the data and the need to improve! As we all look at schemes to implement P4P programs, we need to have a healthy skepticism about their value in driving outcomes and always remember that the real driver is the Hippocratic Oath we all took!

Let’s commit to keeping medicine a noble profession. As William Osler said,

“The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head. Often the best part of your work will have nothing to do with potions and powders, but with the exercise of an influence of the strong upon the weak, of the righteous upon the wicked, of the wise upon the foolish.”

Striving to bring quality to life,
Allen R. Nissenson, MD

Follow me on Twitter @DrNissenson

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⁽¹⁾  www.nytimes.com/2013/01/28/opinion/paying-doctors-for-performance.html?_r=0

(2) http://www.nytimes.com/2013/01/28/opinion/keller-carrots-for-doctors.html?pagewanted=all

(3) Houle SKD et al. Does Performance-Based Remuneration for Individual Health Care Practitioners Affect Patient Care? Ann Intern Med 157:889–899, 2012.

⁽⁴⁾  Mannion R, Davies HT. Payment for Performance in Health Care. BMJ 336:337:a867, 2008.

⁽⁵⁾  Patwardhan MB et al. Clin J Am Soc Nephrol 2:277–283, 2007.

(6) Haley WE. Personal communication, 2012.