Bioethics Blogs

The Cost of Paying for Performance

Katharine Browne raises doubts about the motivational model upon which pay for performance (P4P) schemes are built. Physicians are not selfish knaves. 

Pay for performance (P4P) schemes are alternatives or supplements to the traditional ways of paying physicians. These schemes are adopted as a means of boosting quality and efficiency in healthcare delivery. Improving efficiency is an urgent concern with the expiry of Canada’s health-care accord.

P4P schemes attach financial incentives to care and services in order to motivate the achievement of certain quality measures.  These measures include both specified targeted outcomes (such as the achievement of lower cholesterol levels in cardiac patients), as well as the performance of specific activities (such as advice to increase exercise or to quit smoking).

P4P schemes are well established in the United States and the United Kingdom, and have started to make their way to Canada. The implementation of P4P formed part of Ontario’s Primary Health Care Reform – an undertaking to improve access to, and quality of, care at the first point of contact between the patient and the healthcare provider.

The success of P4P is hard to measure, but it hasn’t been overwhelming. For example, it appears that there have been minimal increases in efficiency and quality of care.

28935980_mP4P can also produce unintended consequences, such as physicians gaming the system in an attempt to reap financial rewards without actually meeting the specified outcomes.  Consequently, much discussion surrounding P4P schemes has focused on which activities should be incentivized, the appropriate level of incentive needed to generate the desired result, how to rank and value outcomes, and how to monitor and assess performance.

The views, opinions and positions expressed by these authors and blogs are theirs and do not necessarily represent that of the Bioethics Research Library and Kennedy Institute of Ethics or Georgetown University.