The Risks of Rewards in Health Care: How Pay-for-performance Could Threaten, or Bolster, Medical Professionalism

P ay-for-performance incentive programs are born of attempts to answer the following question: How can we pay health-care professionals, and doctors in particular, so that they will be motivated to provide high-quality care?This question has several components that deserve careful attention. HOW SHOULD WE PAY DOCTORS?How best to pay doctors is an interesting and long-standing dilemma.George Bernard Shaw-a great critic of the capitalist enterprise-once complained of the fact that "any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting off your leg, is enough to make one despair of political humanity." 1 Following Shaw, there have been a long string of harsh critics of the dominant fee-for-service payment model in medicine.Buttressing these critics have been empirical studies showing that physicians, on average, respond to the fee-for-service incentive as expected, by providing more services, including some that may be of marginal value, useless or even harmful.2,3 The opposite incentive however-paying physicians more for doing less-has an equally fervent set of critics.When capitated payment models came to the fore in the 1990s, both doctors and patients rose up in protest.4 Creating an incentive system in which physicians might earn more by withholding useful care was widely seen as a frontal assault on traditional medical professional values.Doctors who might in any way consider promoting the interests of insurers rather than patients have been called "Schmoctors" among many other, mostly unprintable, epithets.5 In the meantime, US health-care costs are dramatically higher, and rising faster, than costs in other countries.6 The quality of care we deliver is, broadly speaking, mediocre.7 And health-care purchasers are fed up with paying more and more for a product of uneven or uncertain value.8 Given the central role of physicians in health-care delivery and the long-running arguments over how best to pay them, it should be no surprise that one possible answer is developing a payment scheme that gives doctors financial incentives to provide high-quality, costeffective care.