Chris Del Mar

FINANCIAL incentives (“pay-for-performance”) are increasingly being used as a carrot to drive clinician behaviour.

It is certainly true that we often don’t do the things we ought to (such as prescribe warfarin for patients with atrial fibrillation and use beta-blockers in heart failure), and do things we ought not (such as over investigate low-risk patients with atypical chest pain, over-repeat cholesterol tests, and overuse antibiotics in acute respiratory infections).

As well, our fee-for-service system is not well designed to finance complex care for chronic conditions so anything that boosts appropriate care is worth exploring.

However, there is growing concern that financial incentives don’t always work. Experience from a number of sources suggests that there are a number of ways in which some incentives don’t just fail, but actually cause more harm than good.

At a 2-day conference last year we got together with a group of colleagues to nut out the problem, and come up with solutions. Our solution was a checklist, published last week in the BMJ — nine questions that need to be answered satisfactorily before financial incentives are set in place:

1. Do we know that the proposed clinical activity will improve patient care? The UK Quality and Outcomes Framework (QOF), designed to set targets to get GPs to lift their game, chose HbA1c outcome for patients with diabetes as one target at a time when several large trials were underway. Those trials reported that these targets may be totally inappropriate (one trial stopped early because of greater mortality among patients with lower HbA1c levels).

2. Is the financial incentive unnecessary because the change in behaviour is happening anyway? In the above UK initiative, for example, there were several examples of trends in improved care that preceded the QOF.

3. Can we measure the desired clinical behaviour? This is usually the case.

4. Are the necessary systems in place to enable the new clinical behaviour to happen? This is usually not addressed.

5. Do we know that financial incentives are better than alternative interventions? There are a huge variety of alternative strategies and it is important to check that none are more effective than money.

6. Are there unintended harmful consequences? These can include “gaming” the incentive (distorting its intent for pecuniary advantage — commonly found in hospital incentive schemes). Dropping other important activities in favour of those incentivised is also a problem (eg, the QOF resulted in UK GPs reducing teaching of medical students, and also may have harmed the GP‒patient relationship by chasing targets contrary to the patient’s best interests). More subtle is the demotivation that can occur if the doctor’s focus is switched to financial gain, rather than the altruism, professional satisfaction or commitment to patients.

If all of these questions can be answered satisfactorily, then there are operational questions:

7. Are the necessary external conditions in place? For example, when the Medicare-funded immunisation co-payment to GPs was initially introduced, there was a cold-chain failure in rural areas that immediately became apparent.

8. How much should the incentive payment be, and for how long? What happens when the incentive stops? In the QOF, some of the targets reverted when payment stopped. Or should it continue indefinitely?

9. How should the incentive payment be delivered? Who is it paid to (the practice for reinvestment, the individual GPs as income supplement, or does the corporate owner take it as extra profit)?

Financial incentives can and have contributed to driving changes for the better in clinical behaviour.

However, they are not without risk. Our checklist may help policymakers avoid unintended consequences that can leave the system worse off.

Professor Chris Del Mar is director of the Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, Queensland. Professor Mark Harris is executive director of the Centre for Primary Health Care and Equity at the University of NSW.

Posted 20 August 2012