Including Specialists in Pay-for-Performance Presents Challenges

While pay-for-performance programs are gaining traction, most programs have focused on primary care and not on specialists, according to a recent New England Journal of Medicine report.


In a 2004 survey, 27.8 percent of primary care physicians reported receiving some quality-related compensation, while only 17.8 percent of medical specialists and 12.6 percent of surgeons reported receiving quality-based compensation.

Including specialists in such programs is challenging for several reasons, according to the NEJM report. It is difficult to develop meaningful metrics, and it is also difficult to decide which of a patient's multiple physicians should be held accountable for particular outcomes, the report suggests.

Other challenges include incorporating appropriate risk adjustment and having the optimal infrastructure to capture the relevant data. Performance data is most easily tracked electronically, but only 15 percent of specialists have adopted basic electronic health records, according to the report.

Specialists should have flexibility in choosing appropriate metrics developed by their respective societies and approved by the National Quality Forum, according to the report. Entire practices and hospitals should also be held accountable for outcomes, as opposed to holding individual physicians accountable. Looking at performance as a collective endeavor encourages greater collaboration, which is linked to higher-quality care. In addition, a framework to engage specialists should include incentives for adopting interoperable electronic records, according to the report.


Read the New England Journal of Medicine report on performance-based programs and specialists.

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