The pitfalls of pay for performance

Pay-for-performance (P4P) can increase the quality of healthcare for the services given from providers; however, unless carefully designed, P4P may create unintended consequences by increasing racial and ethnic disparities and as a result, decreasing access to healthcare.

What Problems Does Pay for Performance Intend to Solve?
The quality of healthcare in the United States is subpar at best, even though we have an extensive amount of resources and technology. During the past decade, pay-for-performance (P4P) programs have been implemented in our healthcare system to induce physicians and hospitals to invest in improving quality of healthcare. During the same period, it has become evident that the quality of care is not consistent among different racial minorities compared to whites. Increasing attempts have been made to develop interventions to help physicians and hospitals reduce this disparity.

While the traditional fee for reimbursement service methods has been paying for physician services that use recognized and acceptable fee schedule, payments for healthcare reward providers for the patient care volume. The greater the service amount, the higher the compensation and vice versa. With this model of incentive, the costs of health care are increasing at an alarming rate of 5.3 % annually. In the year 2014, health care system accounted for 17.7 % of the Gross Domestic Product (GDP), and economic projections indicate that it will reach 19.6% of the GDP by the year 2024. Even with these different costs, the U.S health care system is at the lowest rank among industrialized nations regarding price, quality, efficiency, health care outcomes and access dimensions.

The U.S. healthcare system is at the lowest rank because the ranking considers the entire nation's population rather than the privileged people who can pay no matter the cost. The financial burden of increasing healthcare costs as well as relatively poor outcomes have been forcing medical policy makers to invent alternate payment models to ensure the provision of greater value. Pay for Performance was created to ameliorate patient access while at the same time controlling costs and maintaining quality. Healthcare payments by the public and private payer will reimburse providers by complex formulas incorporating P4P in the reimbursements. Credible estimations indicate that, by the year 2020, 50% of compensations by CMC (Center for Medicare and Medicaid Services) will embrace an alternative P4P model. The common practice of regulating and reimbursing medicine by private and governmental healthy policy tries to balance quality, cost, and access to care.

It is very important to address stipulations regarding the scope of this article. First, it is assumed that an increase in health disparities directly leads to a decrease in access to care. Second, P4P should be understood as an external incentive; it is assumed that a physician has a desire to provide better care. Third, the term “external incentives” refers to P4P rewards. Fourth, the term “minority patients” refers to patients who are members of ethnic/racial minority groups. Fifth, there is an assumption that “minority patients” vary tremendously in income and education. Sixth, the term “at-risk patients” typically encompasses the “minority patients.” Seventh, the unintended consequences discussed are likely to be more severe for the more disadvantaged range of these at-risk/minority patients. It is important to not misconstrue what is being said. Although the low-income, poorly educated white patients are not usually included in the term “minority patients,” it is important to note that similar unintended consequences of external incentive programs may increase health care disparities between affluent and poor whites as well.

What is Access to Care?
There is a need first to evaluate what it means by “access to health care” to have a solid understanding of the impact of P4P on healthcare access. Due to the complexity of the concept of health care access, we require four dimensions for evaluation. First, is the availability of services with an adequate supply which implies that there exists an opportunity to "have access." Services have to be available in order for patients to have access. Second, the extent to which a particular population gains access surpasses the financial and socio-cultural barriers that may limit or hinder the utilization of services. Patients need to be able to afford healthcare services; healthcare must bridge the gap for patients who come from different backgrounds. Third, the measurement of access is utilization, which is proportional to the availability of services, physical accessibility, and affordability. If patients are utilizing the services, there is access to care. Fourth, there should be an existence of services to gain access to satisfactory health results. There is the need to consider the availability of services as well as barriers to access in the context of different aspects, health needs, and cultural affiliations of diverse people in the community.

P4P Increases Disparities in Health Care Delivery
To this day, there are few data and evidence that study P4P. However, these studies suggest that external incentives successfully induce physicians to provide better quality of care. In addition, there are very few data available on the effects of the external incentives on disparities in quality. Many studies, which will be mentioned throughout this article, suggest that such unintended consequences do occur. This article will address three ways in which external incentives for quality may have the unintended consequence of increasing health care disparities and decreasing access to healthcare.

Lower Incomes in Poor Minority Communities.
P4P may adversely affect the income of physicians practicing in minority communities, particularly poor minority communities. This effect on income could potentially reduce the number of physicians who work in such communities.In addition, physicians would be less likely to provide care to minority communities because these providers would receive lower quality scores on health report cards. First, their patient population might include a high proportion of uninsured and Medicaid patients, so there will be less revenue for these physicians to invest in information systems, staff, and the development of organized processes to improve quality. Second, patients in these underserved areas might be less likely to adhere to treatment recommendations and plans.If patients have low levels of formal education or literacy, they may have difficulty understanding or following written instructions for home care and the use of medications. They might be less likely to obtain preventive care such as mammograms and Pap smears and less likely to return for follow-up of abnormal results. If compared directly to physicians in wealthier areas, physicians in poor minority communities might be less likely to receive P4P incentive pay and more likely to be listed in public report cards as poor-quality physicians. Health care plans often require patients to pay higher copayments for seeing these “poor-quality” physicians, resulting in deprived patients not being able to see physicians that are located in their communities. One study conducted by the British National Health Service (NHS) shows that primary care physicians that served lower-income populations had lower quality scores.

Patient Care May Lose Its Holistic Approach
Since physicians want to receive “quality bonuses” from the government, P4P could induce them to focus their time and attention on types of care that are being measured, even though these non-measured areas could be equally as important to the health of the patient. This “teaching to the test,” could disproportionately affect minorities. For example, let us say a physician sees an uneducated diabetic patient who speaks poor English. The physician might focus on making sure the patient has a hemoglobin A1c test but not on the time-consuming task of explaining to the patient how to control his diabetes and blood pressure. Even though the physician finds a solution for the patients’ ailment, the physician is not telling the patient how to take care of himself in the future, which is equally as important as addressing the ailment.

A physician may provide a more holistic approach to a more affluent, English-speaking patient because the physician is more comfortable with that patient or believes that the patient is more capable of adhering to certain treatment plans or because the patient is more assertive in demanding time and explanation from the physician.

Avoiding at-risk patients
P4P might induce physicians to avoid at-risk patients because these patients are perceived to lower their quality scores. An at-risk patient refers to those who have health care costs of higher than average and are traditionally considered to have a greater health care disparity from the population health mean. Physicians typically perceive minority patients as less likely to comply with their treatment plans and more likely to have bad outcomes. Because of wanting to attain these external incentives, physicians will try to avoid minority patients because they perceive them as more likely to have poor outcomes from treatments. New York State studied death rates from coronary artery bypass graft (CABG) surgery for individual surgeons and hospitals and was able to show that there exists an increasing gap between CABG rates for whites and blacks. The conclusion based off of this study appears to have made surgeons more reluctant to operate on black patients.

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