Pay for Performance in Primary Care in England and California: Comparison of Unintended Consequences

When I asked my sister, the high school English Teacher, retired after 33 years at the toughest school in her city, what she thought of the scoring system behind "No Child Left Behind" her comments reminded me of much of what I hear from family medicine colleagues about pay for performance. She said that teaching to scores in a school system like hers where less than 60% of the students finish because of community or family disparities seems impossible compared to suburban schools with intact families and lots of resources. I thought of that as I received my notice from the health plan that my heavily uninsured, non-English speaking diabetic patients with two jobs were not getting their HgbA1C levels under 7. Life is certainly not a level playing field for patients and neither is practice.

All teachers, just like all family doctors, are committed to quality - or at least trying for it. But McDonald and Rowland's article comparing well compensated British GP's with support for overhead and something to gain but nothing to lose with over worked, underpaid family doctors in California who have 30% of their compensation to lose and little overhead support with which to do it does not result in many surprising findings. Practicing to meet standards rather than improvement or care is a demoralizing task and makes doctors want to find "easier" patients.

The sources of dysphoria in primary care are not hard to identify and most P4P programs in the US are not helping things at all. And when new evidence comes out that should change or at least soften the "guidelines" and targets, they are ignored. That might force them to admit that quality might be about process rather than metrics.

The highest rate of improvement in primary care in the US is in the Veteran's Adminstration system, once reviled but now widely emulated. The primary care doctors there work for a salary and have lots of support for their work, and get merit pay based on group performance, not individual achievement. Maybe U.S. insurance companies might learn something from that - if they choose to.

Competing interests:   Associate Editor, Annals of Family Medicine

This well conducted qualitative study supports the notion that the design of quality improvement programs plays a major role in determining outcomes. Too often practitioners see themselves on the outside of decision-making. To be successful, evaluation programs must involve practitioners early in the process and respond to substantive criticisms about accuracy and validity of the data used. In that way, the measures can be internalized and the financial incentives become less intrusive. McDonald and Roland describe that process as follows, "The potential adverse effects of external incentives on motivation are likely to be diminished where individuals identify with the goals and values of incentive programs and feel that they have a degree of autonomy in their delivery. In other words, when designing incentive programs, it is important to consider the manner in which they are implemented and the extent to which the context is perceived as supportive."

These are some of the pillars of relationship-centered care. Accountibility is best accomplished through partnership to improve care rather than a simple "market" reponse to financial incentives.

Competing interests:   None declared