High Quality Care and Ethical Pay-for-Performance: A Society of General Internal Medicine Policy Analysis
Pay-for-performance is proliferating, yet its impact on key stakeholders remains uncertain.
The Society of General Internal Medicine systematically evaluated ethical issues raised by performance-based physician compensation.
We conclude that current arrangements are based on fundamentally acceptable ethical principles, but are guided by an incomplete understanding of health-care quality. Furthermore, their implementation without evidence of safety and efficacy is ethically precarious because of potential risks to stakeholders, especially vulnerable patients.
We propose four major strategies to transition from risky pay-for-performance systems to ethical performance-based physician compensation and high quality care. These include implementing safeguards within current pay-for-performance systems, reaching consensus regarding the obligations of key stakeholders in improving health-care quality, developing valid and comprehensive measures of health-care quality, and utilizing a cautious evaluative approach in creating the next generation of compensation systems that reward genuine quality.
- Rosenthal MB, Landon BE, Normand SL, Frank RG, Epstein AM. Pay for performance in commercial HMOs. N Engl J Med. 2006; 35518: 1895–1902. CrossRef
- Rosenthal MB, Frank RG. What is the empirical basis for paying for quality in health care? Med Care Res Rev. 2006; 632: 135–157. CrossRef
- Petersen LA, Woodard LD, Urech T, Daw C, Sookanan S. Does pay-for-performance improve the quality of health care? Ann Intern Med. 2006; 1454: 265–272.
- Amundson G, Solberg LI, Reed M, Martini EM, Carlson R. Paying for quality improvement: compliance with tobacco cessation guidelines. Jt Comm J Qual Saf. 2003; 292: 59–65.
- Fairbrother G, Hanson KL, Friedman S, Butts GC. The impact of physician bonuses, enhanced fees, and feedback on childhood immunization coverage rates. Am J Public Health. 1999; 892: 171–175. CrossRef
- Kouides RW, Bennett NM, Lewis B, Cappuccio JD, Barker WH, LaForce FM. Performance-based physician reimbursement and influenza immunization rates in the elderly. The Primary-Care Physicians of Monroe County. Am J Prev Med. 1998; 142: 89–95. CrossRef
- Roski J, Jeddeloh R, An L, et al. The impact of financial incentives and a patient registry on preventive care quality: increasing provider adherence to evidence-based smoking cessation practice guidelines. Prev Med. 2003; 363: 291–299. CrossRef
- Wharam JF, Farber NJ, Paasche-Orlow MK, Sinsky C, Rask KJ, Rucker L, Figaro K, Braddock C, Barry M, Sulmasy D. Can Pay-for-Performance be Ethical? An Analysis by the Society of General Internal Medicine Ethics Committee. Available at: http://www.sgim.org/index.cfm?pageId=806.
- Epstein AM, Lee TH, Hamel MB. Paying physicians for high-quality care. N Engl J Med. 2004; 3504: 406–410. CrossRef
- Blumenthal D. The vital role of professionalism in health care reform. Health Aff (Millwood). 1994; 131: 252–256. CrossRef
- Swick HM. Toward a normative definition of medical professionalism. Acad Med. 2000; 756: 612–616. CrossRef
- Wynia MK, Latham SR, Kao AC, Berg JW, Emanuel LL. Medical professionalism in society. N Engl J Med. 1999; 34121: 1612–1616. CrossRef
- Beauchamp TL, Childress JF. Principles of biomedical ethics. 5th ed. New York, N.Y.: Oxford University Press; 2001.
- Davis K, Schoenbaum SC, Audet AM. A 2020 vision of patient-centered primary care. J Gen Intern Med. 2005; 2010: 953–957. CrossRef
- Povar GJ, Blumen H, Daniel J, et al. Ethics in practice: managed care and the changing health care environment: medicine as a profession managed care ethics working group statement. Ann Intern Med. 2004; 1412: 131–136.
- Wharam JF, Paasche-Orlow MK, Farber NJ, Sinsky C, Rucker L, Rask KJ, Figaro MK, Braddock C, Barry M, Sulmasy DP. High Quality Care and Ethical Pay-for-Performance: A Position Statement of the Society of General Internal Medicine. Available at: http://www.sgim.org/index.cfm?section=site&pageId=806. Accessed December 10, 2008.
- Wharam JF, Daniels N. Toward evidence-based policy making and standardized assessment of health policy reform. Jama. 2007; 2986: 676–679. CrossRef
- Committee on Quality of Health Care in America IoM. Crossing the Quality Chasm: A New Health System for the 21st Century. Available at: http://www.nap.edu/catalog/10027.html#toc. Accessed November 14, 2006.
- Lohr KN, Donaldson MS, Harris-Wehling J. Medicare: a strategy for quality assurance, V: Quality of care in a changing health care environment. QRB Qual Rev Bull. 1992; 184: 120–126.
- Brook RH, McGlynn EA, Shekelle PG. Defining and measuring quality of care: a perspective from US researchers. Int J Qual Health Care. 2000; 124: 281–295. CrossRef
- Campbell SM, Roland MO, Buetow SA. Defining quality of care. Soc Sci Med. 2000; 5111: 1611–1625. CrossRef
- Maxwell RJ. Dimensions of quality revisited: from thought to action. Qual Health Care. 1992; 13: 171–177. CrossRef
- Quality of care: 1. What is quality and how can it be measured? Health Services Research Group. Cmaj. Jun 15 1992;146(12):2153-2158.
- Donabedian A. The seven pillars of quality. Arch Pathol Lab Med. 1990; 11411: 1115–1118.
- O’Leary DS, O’Leary MR. From quality assurance to quality improvement. The Joint Commission on Accreditation of Healthcare Organizations and Emergency Care. Emerg Med Clin North Am. 1992; 103: 477–492.
- Harteloh PP. The meaning of quality in health care: a conceptual analysis. Health Care Anal. 2003; 113: 259–267. CrossRef
- Blumenthal D. Part 1: Quality of care–what is it? N Engl J Med. 1996; 33512: 891–894. CrossRef
- O’Neill O. Trust with accountability? J Health Serv Res Policy. 2003; 81: 3–4. CrossRef
- Wharam JF, Paasche-Orlow M, Sinsky C, Farber N, Rask K, Rucker L, Sulmasy D, Barry M, Figaro K. Ethical Issues in Pay-for-Performance: Opinions of SGIM Members. Unpublished. 2008.
- Casalino LP. The unintended consequences of measuring quality on the quality of medical care. N Engl J Med. 1999; 34115: 1147–1150. CrossRef
- Casalino LP, Alexander GC, Jin L, Konetzka RT. General internists’ views on pay-for-performance and public reporting of quality scores: a national survey. Health Aff (Millwood). 2007; 262: 492–499. CrossRef
- Casalino LP, Elster A, Eisenberg A, Lewis E, Montgomery J, Ramos D. Will pay-for-performance and quality reporting affect health care disparities? Health Aff (Millwood). 2007; 263: w405–414. CrossRef
- Fisher ES. Paying for performance–risks and recommendations. N Engl J Med. 2006; 35518: 1845–1847. CrossRef
- Hayward RA. All-or-nothing treatment targets make bad performance measures. Am J Manag Care. 2007; 133: 126–128.
- Hayward RA. Performance measurement in search of a path. N Engl J Med. 2007; 3569: 951–953. CrossRef
- Wodchis WP, Ross JS, Detsky AS. Is P4P really FFS? Jama. 2007; 29815: 1797–1799. CrossRef
- Wachter RM, Shojania KG. The unintended consequences of measuring quality on the quality of medical care. N Engl J Med. 2000; 3427: 520. CrossRef
- Volandes AE, Paasche-Orlow MK. Health literacy, health inequality and a just healthcare system. Am J Bioeth. 2007; 711: 5–10.
- Lo B, Groman M. Oversight of quality improvement: focusing on benefits and risks. Arch Intern Med. 2003; 16312: 1481–1486. CrossRef
- Bellin E, Dubler NN. The quality improvement-research divide and the need for external oversight. Am J Public Health. 2001; 919: 1512–1517. CrossRef
- Casarett D, Karlawish JH, Sugarman J. Determining when quality improvement initiatives should be considered research: proposed criteria and potential implications. Jama. 2000; 28317: 2275–2280. CrossRef
- Kofke WA, Rie MA. Research ethics and law of healthcare system quality improvement: the conflict of cost containment and quality. Crit Care Med. 2003; 313 Suppl: S143–152. CrossRef
- Perneger TV. Why we need ethical oversight of quality improvement projects. Int J Qual Health Care. 2004; 165: 343–344. CrossRef
- Nerenz DR, Stoltz PK, Jordan J. Quality improvement and the need for IRB review. Qual Manag Health Care. 2003; 123: 159–170.
- Lynn J, Baily MA, Bottrell M, et al. The ethics of using quality improvement methods in health care. Ann Intern Med. 2007; 1469: 666–673.
- Strasberg SM, Ludbrook PA. Who oversees innovative practice? Is there a structure that meets the monitoring needs of new techniques? J Am Coll Surg. 2003; 1966: 938–948. CrossRef
- Marron JM, Siegler M. Ethical issues in innovative colorectal surgery. Dis Colon Rectum. 2005; 486: 1109–1113. CrossRef
- Bunker JP, Hinkley D, McDermott WV. Surgical innovation and its evaluation. Science. 1978; 2004344: 937–941. CrossRef
- Cronin DC 2nd, Millis JM, Siegler M. Transplantation of liver grafts from living donors into adults–too much, too soon. N Engl J Med. 2001; 34421: 1633–1637. CrossRef
- Reitsma AM, Moreno JD. Ethical regulations for innovative surgery: the last frontier? J Am Coll Surg. 2002; 1946: 792–801. CrossRef
- Reitsma AM, Moreno JD. Ethics of innovative surgery: US surgeons’ definitions, knowledge, and attitudes. J Am Coll Surg. 2005; 2001: 103–110. CrossRef
- Margo CE. When is surgery research? Towards an operational definition of human research. J Med Ethics. 2001; 271: 40–43. CrossRef
- Amoroso PJ, Middaugh JP. Research vs. public health practice: when does a study require IRB review? Prev Med. 2003; 362: 250–253. CrossRef
- HCAHPS. CAHPS Hospital Survey. Available at: http://www.hcahpsonline.org/. Accessed February 10, 2008.
- Cheraghi-Sohi S, Hole AR, Mead N, et al. What Patients Want From Primary Care Consultations: A Discrete Choice Experiment to Identify Patients’ Priorities. Ann Fam Med. 2008; 6: 107–115. CrossRef
- Rao M, Clarke A, Sanderson C, Hammersley R. Patients’ own assessments of quality of primary care compared with objective records based measures of technical quality of care: cross sectional study. Bmj. 2006; 3337557: 19. CrossRef
- Massachusetts Co. An Act Providing Access to Affordable, Quality, Accountable Health Care. Available at: http://www.mass.gov/legis/laws/seslaw06/sl060058.htm.
- Weinick RM, Alegria M, Coltin K, Gannon PM, Goel AK. Disparities in Health Care in the Massachusetts Medicaid Program Recommendations of the Massachusetts Medicaid Disparities Policy Roundtable. Available at: http://www.cms.hhs.gov/MedicaidSCHIPQualPrac/Downloads/disp4p.pdf. Accessed November 24, 2008.
- Kent DM, Hayward RA. Limitations of applying summary results of clinical trials to individual patients: the need for risk stratification. Jama. 2007; 29810: 1209–1212. CrossRef
- Daniels N, Sabin JE. Setting limits fairly : can we learn to share medical resources? Oxford, New York: Oxford University Press; 2002.
- High Quality Care and Ethical Pay-for-Performance: A Society of General Internal Medicine Policy Analysis
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Journal of General Internal Medicine
Volume 24, Issue 7 , pp 854-859
- Cover Date
- Print ISSN
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- health policy
- quality improvement
- physician reimbursement
- Industry Sectors
- Author Affiliations
- 1. Department of Ambulatory Care and Prevention, Harvard Medical School and Harvard Pilgrim Health Care, 133 Brookline Avenue, 6th Floor, Boston, MA, 02114, USA
- 2. Department of Medicine, Boston University School of Medicine, Boston, MA, USA
- 3. University of California, San Diego, CA, USA
- 4. Medical Associates Clinic and Health Plan, Dubuque, IA, USA
- 5. Albert Einstein College of Medicine, Bronx, NY, USA
- 6. Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA, USA
- 7. Department of General Internal Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
- 8. Department of Medicine, Stanford University School of Medicine, Stanford, CA, USA
- 9. Medical Practices Evaluation Center, General Medicine Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- 10. St. Vincent’s Hospital, Manhattan and New York Medical College, New York, USA