Lois Snyder, JD; Richard L. Neubauer, MD; American College of Physicians Ethics, Professionalism and Human Rights Committee
Acknowledgment: The ACP Ethics, Professionalism and Human Rights Committee thanks the following reviewers of drafts of this paper: Patricia P. Barry, MD; Peter Basch, MD; Donald E. Casey, MD, MPH, MBA; Sima S. Desai, MD; S.A. Dean Drooby, MD; Herbert I. DuPont, MD; Faith T. Fitzgerald, MD; Robert B. Gibbons, MD; Robert A. Gluckman, MD; Rodney Hornback, MD; Mark Liebow, MD; Kay M. Mitchell, MD; L. Gregory Pawlson, MD; Laura Petersen, MD, MPH; Eric C. Schneider, MD, MSc; Michael C. Sha, MD; Bruce Vladick, PhD; Kathleen Weaver, MD; F. David Winter, Jr., MD, MSc.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Lois Snyder, JD, American College of Physicians Center for Ethics and Professionalism, 190 N. Independence Mall West, Philadelphia, PA 19106; e-mail, email@example.com.
Current Author Addresses: Ms. Snyder: American College of Physicians Center for Ethics and Professionalism, 190 N. Independence Mall West, Philadelphia, PA 19106.
Dr. Neubauer: Alaska Native Medical Center, 4315 Diplomacy Drive, Anchorage, AK 99508.
This paper, written by Lois Snyder, JD, and Richard L. Neubauer, MD, was developed by the American College of Physicians (ACP) Ethics, Professionalism and Human Rights Committee. Members of the Ethics, Professionalism and Human Rights Committee were Frederick E. Turton, MD (Chair); Richard A. Hranac, MD (Vice Chair); Neil J. Farber, MD; Virginia L. Hood, MD, MPH; Allen S. Keller, MD; Diane E. Meier, MD; Paul S. Mueller, MD, MPH; Richard L. Neubauer, MD; Mahmoud Sharaf, MD; and Peter A. Ubel, MD. This paper is based on a longer position paper approved by the ACP Board of Regents on 29 October 2006 and is available on the ACP Web site at http://www.acponline.org.
Snyder L., Neubauer R., ; Pay-for-Performance Principles That Promote Patient-Centered Care: An Ethics Manifesto. Ann Intern Med. 2007;147:792-794. doi: 10.7326/0003-4819-147-11-200712040-00011
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Published: Ann Intern Med. 2007;147(11):792-794.
Pay-for-performance programs are growing, but little evidence exists on their effectiveness or on their potential unintended consequences and effects on the patientâ€“physician relationship. Pay-for-performance has the potential to help improve the quality of care, if it can be aligned with the goals of medical professionalism. Initiatives that provide incentives for a few specific elements of a single disease or condition, however, may neglect the complexity of care for the whole patient, especially the elderly patient with multiple chronic conditions. Such programs could also result in the deselection of patients, â€œplaying to the measuresâ€ rather than focusing on the patient as a whole, and misalignment of perceptions between physicians and patients. The primary focus of the quality movement in health care should not be on â€œpay forâ€ or â€œperformanceâ€ based on limited measures, but rather on the patient. The American College of Physicians hopes to move the pay-for-performance debate forward with a patient-centered focusâ€”one that puts the needs and interests of the patient firstâ€”as these programs evolve.
University of Texas Medical Branch, Galveston
December 7, 2007
Pay-for-performance and Professionalism
Snyder et al. correctly depict pay-for-performance as a possible threat to professionalism in medicine. (1) The contradiction between professionalism and pay-for-performance is, however, more serious than they acknowledge.
The core concept of professionalism is the physician's willingness to put self-interest aside and to address the interests of the patient as the first priority.(2) Pay-for-performance is ultimately predicated on the idea that we can get physicians to serve patients well only by appealing to their self-interest. The models are radically contradictory.
Are all financial incentives designed to improve physician behavior, in ways that would better serve patients, therefore unprofessional? That, in turn, seems too radical a statement. Professionalism requires that the patient-physician relationship never be reduced to a purely mercantile encounter; yet many aspects of medical practice can be improved by the use of good business methods. The line between financial incentives that support professional behavior, and incentives that undermine professional behavior, may be a fine one, as debates over the ethics of the relationship between medicine and the pharmaceutical industry illustrate.(3) Pay-for-performance proposals can navigate these risks only if they are subjected to considerably more ethical scrutiny than they have received to date.
1. Snyder L, Neubauer RL. Pay-for-performance principles that promote patient-centered care: an ethics manifesto. Ann Intern Med. 2007;147:792- 4.
2. Cohen JJ. Viewpoint: linking professionalism to humanism: what it means, why it matters. Acad Med. 2007; 82:1029-32.
3. Brody H. Hooked: ethics, the medical profession, and the pharmaceutical industry. Lanham, MD: Rowman and Littlefield, 2007.
Christopher M. Lowther
Big Horn Basin Skin Centre
December 17, 2007
The paper by Snyder and Neubauer about Pay for Performance and Medical Ethics falls short. Recently I had a husband and wife, both overweight diabetics, who became angry with me when I discussed the need to diet. I held my tongue and did not turn them away.
In the 1930s when Germany developed the first antibiotic sulfa drugs, only the United States allowed their use without adequate research, and multiple patients died from dangerous unregulated formulations. Hence the FDA.
Don't we have a responsibility to patients to first test any system to see if there is any validity in it? Should not Pay for Performance be tried with a test population to see if the concept really works?
This program will especially affect the physicians and patients in small practices that don't have the resources to put it into practice. Large clinics and their satellites can hire extra clerical clerks and at least not lose money. But what about the rest of us? Although your authors stae it would be unethical for physicians to drop more difficult patients, it definitely will happen. There is a history of attempted litigation against managed care companies, for restriction of care only to be safeguarded by unethical government protection. Internists that can will retire earlier, making untried legislation an ugly situation. When government gets between patients and their physician everyone will lose.
Paulette M. Metoyer
January 10, 2008
Comments on P4P
To the Editor:
It was gratifying to read Snyder and Neubauer's Position Paper on Pay -for-Performance (P4P) and to see that I am not alone in my concerns over these initiatives. There are a few issues upon which I would like to comment:
First, because providers are the only certain beneficiaries of P4P, the implementation of these programs, without evidence of patient benefit, is inconsistent with the ethical imperative that "Clinicians must insure that"¦ a medically appropriate level of care takes precedence over personal consideration." In that regard P4P seems inherently unethical.
Second, the goal of diminishing substandard care is an acknowledgement of widespread failure of the medical profession to meet the "professional duty to provide high quality care to each patient," while accepting payment for doing so. In place of a coordinated action plan (which could include limitations on scope of practice, disciplinary action, etc.) to address substandard care, P4P gives precedence to the considerations of the medical profession by offering more money to underachieving providers to do in the future that for which they were paid (and failed) to do in the past "“ that for which their on par colleagues did without financial inducement. Are patients not entitled to quality care that meets professional standards upon the initial payment, just as we are all entitled to goods and services that meet industry standards in any other business transaction? Extra money should not be necessary for the providers of services to meet their own industry standards.
Third, by failing to recognize the difference between physicians who performed the minimal one or two years of post-graduate training required for licensure from those who completed residency and fellowship training P4P devalues Internal Medicine and its subspecialties. It condenses years of training into a brief list of performance parameters and perpetrates the myth that all doctors possess the same knowledge and skill sets.
Finally, is there any doubt that the increased profitability of the diseases included in the performance parameters, will parallel an increase in reported frequency? I offer two simple examples of what I have seen in the insurance industry: 1) A diagnoses of "diabetes/diet controlled" used to justify extensive and repetitive laboratory testing - not limited to glucose and hemoglobin A1C, but including chemistry panels, CBC, fructosamine, etc. The meaning of the term is speculative as record review may show increased body weight, but no past or present evidence of diabetes. 2) "Hypertension/diet controlled," in patients with no convincing evidence of hypertension, used to justify repetitive electrocardiograms, echocardiograms, stress testing, renal perfusion scans, etc. Because P4P lacks diagnostic and exclusionary criteria, word games of this nature will proliferate - and in the absence of oversight, remain hidden. The inaccurately reported data will contaminate public health and other demographic records used by government and private industry to determine budgetary allocations.
Sincerely, Paulette Metoyer M.D., F.A.C.P.
February 5, 2008
Pay-for-Performance Ethics Response from ACP
We appreciate Dr. Metoyer's thoughtful comments, many of which the ACP Ethics, Professionalism and Human Rights Committee agree with in the College's pay-for-performance (P4P) ethics position paper (1). We do not agree, however, with her conclusion that P4P programs in some regards seem inherently unethical. Every payment system creates incentives and potential conflicts of interest, such as the incentives in fee-for-service payment to increase care or the incentives under capitation to do less rather than more. The College believes P4P programs have promise, if they can be focused on patient perspectives on care and on professionalism, including the duty to ensure medically appropriate care above financial and other considerations. As pointed out in the ACP Ethics Manual, "Medical practice"¦ does not stand still. Clinicians must be prepared to deal with changes and reaffirm what is fundamental"(2). The P4P ethics paper attempts to lay out principles that may guide clinicians in dealing with P4P programs, as well as provide ethical guidance to those who would design such systems. In addition, the problem that current payment systems reward substandard care, then pay again to fix that care, is a concern that goes beyond P4P programs.
Dr. Lowther suggests that P4P is an untested strategy to improve quality of care and that the concept should be tested before being instituted in widespread fashion. We noted the lack of evidence of effectiveness in our paper. Non-governmental payers are looking at that now in our market-based system, and questions have begun to appear regarding the effectiveness of P4P strategies in this setting (3). Dr. Lowther also implies that P4P is primarily a government function but that is not currently the case. In fact, the Physician Quality Reporting Initiative (PQRI ) program instituted by the Centers for Medicare & Medicaid Services (CMS) thus far is not a P4P program but rather a pay-for -reporting program with modest monetary incentives. Nonetheless, we do agree that the risk of de-selection of patients is serious, and sound a cautionary note that the risk may increase if P4P programs grow in the current payment environment.
Dr. Brody raises the specter that P4P may threaten medical professionalism even more than depicted in our paper. The College's hope is to redirect the evolution of incentives for quality by insisting on a focus that puts the needs of the patient first. Fundamental reform of the payment system to encourage comprehensive coordinated care of the patient would achieve much more than widespread deployment of P4P. If that were to happen, P4P programs could play a small but significant role in encouraging certain outcomes as long as professionalism principles and safeguards against unwanted outcomes were built-in.
Richard L. Neubauer, MD, FACP Member, ACP Ethics, Professionalism and Human Rights Committee
Lois Snyder, JD Director, ACP Center for Ethics and Professionalism
(1) Snyder L, Neubauer RL for the American College of Physicians Ethics, Professionalism and Human Rights Committee. Pay-for-performance principles that promote patient-centered care: an ethics manifesto. Ann Intern Med. 2007;147:792-794.
(2) American College of Physicians. Ethics Manual. Fifth edition. Ann Intern Med. 2005; 142: 560-582.
(2) Rosenthal, MB; Landon, BE; Normand, SLT, Frank, RG; Ahmad TS, Epstein AM. Employers' use of value-based purchasing strategies. JAMA. 2007; 298: 2281-2288.
Submitted February 5, 2008
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