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GROUPS representing doctors want serious potential drawbacks in pay-for-performance (P4P) in general practice addressed before the scheme is introduced in Australia.
The AMA and RACGP say they are worried that such a system may not result in better quality care for patients.
An article published in this week’s Medical Journal of Australia says key lessons must be learned from the UK and US before P4P is implemented here.(1)
The authors said the National Primary Health Care Strategy,(2) released with this year’s federal budget, recommended P4P as a key building block in the reform of the health system.
However, they said rewarding a specified level of quality might not be as effective as rewarding improvements in quality.
“For those already providing high-quality care, the reward represents a windfall financial gain with no incentive to change behaviour,” they said.
Rewarding a threshold of quality did not encourage further improvements in quality, and for doctors with very low baseline levels of quality, the costs of achieving a relatively high threshold might seem prohibitive and they might not participate.
“Pay-for-performance should be used to drive quality improvement, not simply to reward those who are already providing high-quality care,” the authors said.
AMA president Dr Andrew Pesce said the MJA article raised the question of whether doctors not providing high-quality care could be paid more through incentives than doctors who were.
It could also mean doctors and practices unable to achieve specified targets missed out on funding, even though they might need more support.
“For example, they might have a more difficult group of patients,” Dr Pesce said.
RACGP president Dr Chris Mitchell said some serious questions needed to be answered before Australia went down the path of P4P.
“If you look at the international literature around pay-for-performance, what is absolutely clear is that it is not helpful to be targeting disease-specific guideline outcomes,” he said.
“Performance must include quality of life indicators and satisfaction with the care that is being delivered, rather than blindly following a range of different guidelines that may have no relevance to the particular patient.”
Practitioners “doing the hardest yards” must receive the greatest support, Dr Mitchell said.
Dr Pesce said there was not strong evidence that P4P improved quality of care.
“You get a target, you achieve a target, but often the targets seem to be designed because they are easy to measure, not because they actually reflect quality,” he said.
A huge amount of consultation with the medical profession to address concerns would be needed before P4P was introduced, but the government had not approached the AMA, he said.
1. Med J Aust 2010; 193: 408-411.
2. National Primary Health Care Strategy.
Posted 5 October 2010
I have railed passionately against pay-for-performance previously [because of the inequity if you have more complex patients] and it is pleasing to now see the AMA and RACGP warnings – however, the AGPN which is funded by the government seems to be silent, continuing its ideological push for bureaucratic “supermarket medicine” which includes pay-for-performance in its manifesto.
What P4P means is you get paid if you do what the government tells you to do, because the government puts up the goal posts. What the government wants you to do is to help it control and contain health care costs by rationing care, but to have someone else like you actually standing there to take the blame and do the rationing.
I think everyone has missed the real purpose of ‘pay for performance’ incentives. The data collected is a political goldmine to an incumbent government, enabling it to claim statistical validation of either or both of ‘high quality care’ and ‘substantial improvements in care’, even if patients at the coal-face are grumbling.
And who determines what constitutes “quality”? For example lower and lower HbA1C levels are being questioned.So paying for this may seem like quality but may not be.Also are we interested in cholesterol levels (easy to measure)or heart attack rates(what matters but influenced by multiple factors)
Ultimately the problem is that performance will be based on what can be measured easily rather than what counts.
Also unless I am in a position to control every single action of patients then their health remains their responsibility.I can advise but not put my head on their shoulders