Are quality based incentive programs the solution for improving physician quality without increasing cost? While I believe that measuring quality is an important avenue by which quality can be improved, it is not a magic bullet. A study by Gilmore, et al. (HSR 2007) looks at a pay-for-performance scheme developed in Hawaii. The authors look at administrative claims data for a large BC/BS PPO (Hawaii Medical Services Association). After the PPO implemented the Physician Quality and Service Recognition (PQSR) pay-for-performance program, recommended care metrics increased on the measured dimensions.
One issue is whether or not the quality increased in the medical care dimensions not measured by the PQSR. For instance, a physician may being to care less about medical care which is not captured by PQSR or may decide to shift resources from procedures not measured by PQSR to measures by which their bonuses are calculated. Also, the physician may provide inappropriate care to some patients just to reach the appropriate bonus. The authors note some other issues:
- Patient demand may drive some of the compliance rates. Low compliance rates were found for colorectal and cervical cancer screening, but this is likely due to the fact that the patients find that undergoing these procedures is unpleasant at best. Thus, the physician may not be at fault for the low compliance rates.
- Quality indicators that require specialist physician visits often have low compliance rates as well (e.g.: retinal exam for diabetics). This may by due to the added expense the patient must incur in order to receive the prescribed care.
- Finally, one may worry that performance-based metrics do not adequately take into account the physicians case mix.
While pay-for-performance or quality rating systems have the potential to increase quality throughout the medical system, these performance metrics, must be very carefully designed to take into account many of the issues addressed above.