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The Medical Professionalism Blog

Exploring What Works to Improve Care: Hold the Money, Pass the Praise

On November 18th, the American Board of Internal Medicine, through a grant from the Agency for Healthcare Research and Quality, the Robert Wood Johnson Foundation and the ABIM Foundation, conducted a conference entitled, “Physician Level Assessment and Recognition: What Works?” The basis of the conference was a yet-to-be-published systematic literature review that compares the efficacy of pay-for-performance, pay-for-reporting, public reporting, assessment and feedback, and certification as means to improve the quality of health care.

Since the paper is not published, I will not be reporting on its findings. Rather, I want to talk about my impressions of the conversation had among national leaders from health plans, health systems, the policy community, consumer groups and researchers.

Much of the conversation focused on the virtues and weaknesses of pay-for-performance, otherwise known as “P4P.”

My takeaways:

1) We don’t know with any certainty if P4P improves the quality of care. I guess that’s OK — on the surface, it makes sense. What is disturbing was the lack of a firm commitment to evaluate it in the future. Rather, the battle cry was, “We don’t have the time to evaluate it. Things are moving too fast.”

2) There was not much discussion about what is being rewarded. Subsequently, there is little information on what is valued in the health care system and by whom — purchasers, physicians or patients?  Decades ago, health plans wanted to be affordable and provide a comprehensive set of benefits so group practices were rewarded for reducing hospital days. Do current P4P programs reward physicians for care coordination, patient engagement and communication, teamwork and diagnostic abilities? Or do they reward primarily on reductionist clinical measures like lowering hemoglobin levels and lipids? What are they valuing in their rewards?

3) There were interesting conversations about intrinsic versus extrinsic motivation around rewards and recognition to enhance the quality of health care. Many agreed that the extrinsic rewards (such as money and recognition) should reinforce the more intrinsic motivations of mastery, purpose and autonomy of the profession. A few in the room believed extrinsic motivation trumps intrinsic despite decades of evidence that shows that performance is better under an intrinsic framework.

4) Within P4P, approaches vary greatly. It’s hard to know what the key components are that stimulate a change in performance. Is it:

  • The size of the reward?
  • The proximity of performance to the reward?
  • The perceived importance of the measure to the clinician and patient?
  • The degree of difficulty to improve on a given performance measure?

In some P4P programs, it was reported that the clinicians were unaware of the performance measures and even the P4P program’s existence.

5) A medical educator at the conference stated that P4P would not pass the test for an acceptable educational curriculum. Goals of P4P are not clear and how to go about achieving success is not well-articulated.

6) Most of the participants agreed that to drive improvement, we need to reinforce system approaches to quality of care and not focus on the individual clinician. Yet why do we base many P4P programs on individual performance? Other external forces that focus on individual performance, for example, certification and maintenance of certification, could comprehensively assess individual physician competency and performance and drive individual improvement. Other assessors could examine the performance of systems of care.

I wonder how a physician experiences all of these P4P programs. Everyone wants to be recognized for his or her performance — with or without financial rewards. If we lifted pay from performance and just focused on the recognition, would we get the same results, or better? In Minneapolis, public reporting of performance by groups of physicians, not individual, has eclipsed P4P. The performance of their physician groups is one of the best in the land.

What do you think is the best way to recognize and reward physicians?

2 Comments to Exploring What Works to Improve Care: Hold the Money, Pass the Praise

  • December 12, 2011 at 8:06 am | Permalink

    This “free sarhing” of information seems too good to be true. Like communism.

  • Geof Williams's Gravatar Geof Williams
    December 6, 2011 at 2:09 pm | Permalink

    Nicely summarized Daniel. I have a couple of ideas here for those of you interested in theories. Many times I hear or see in print that rewards may ‘reinforce’ autonomy or intrinsic motivation. I will be a little picky and offer that self-determination theory has a different mechanisim of change (internalization of value for) than does behavioral theory (reinforcement). In the world of theories, it is inconsistent that autonomy can be reinforced- rewards are controlling and therefore work against internalization. Remember, it is after the rewards are stopped that we see the undermining effect. Behavioral theory has no mechanism for how people take in regulations to own them for themselves. SDT offers internalization as that ‘maintanence mechanism and it has been shown to be present in several studies.

    Here is another idea- that we can have/experience intrinsic and extrinsic motives at the same time. Being human is complicated!

    In any event, as Daniel summarizes, in education and many life domains, rewards undermine intrinsic motivations. We know less about what rewards to extrinsic motivations-that is a very exciting area of research in health areas.

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