To the Editor: As a general practitioner in England, I and thepractice in which I work were directly affected by the changesmade in 2004 by the introduction by the National Health Serviceof a pay-for-performance contract for family practitioners,as reported by Doran and colleagues (July 27 issue).1 The contractwas evidence based, ensuring that the majority of general practitionersapproved of its aims.
Doran and colleagues omitted a number of important lessons thatcan be drawn from that experience. First, the necessity to "tickboxes" to ensure that tasks triggering payment were completedhad a major effect on many consultations each day. Second, muchbigger than the payments to general practitioners were the increasedconsequential costs triggered by the quadrupling of prescriptionsfor statins. Third, there was the effect on the local hospitalsof a sudden increase in referrals for investigative proceduressuch as echocardiography for heart failure and cardiologic referralsfor angina — conditions that previously had often beendealt with without referrals. Fourth, there is the increasedmedication load for patients — typically, a patient withdiabetes has to take 10 different therapies.
Andrew A.F. Sanderson, M.B., B.S. St. Andrew's Medical Practice Spennymoor DL16 6QA, United Kingdom andrew.sanderson{at}gp-a83001.nhs.uk
References
Doran T, Fullwood C, Gravelle H, et al. Pay-for-performance programs in family practices in the United Kingdom. N Engl J Med 2006;355:375-384. [Free Full Text]
To the Editor: In his editorial accompanying the article byDoran and colleagues, Epstein1 encourages the United Statesto adopt a system similar to that introduced in the United Kingdom.Although financial incentives could change doctors' behavior,2it is difficult to ascertain whether the achievement reportedby Doran et al. is due solely to incentives or to an improvementin clinical practice in general, since there is no control groupand there are no baseline data. In our area, organizationalcare indicators for diabetes, such as data recording, have increaseddramatically, but clinical indicators, such as cholesterol levelsand glycated hemoglobin values, have revealed a smooth increasethat might be due to other factors, such as the use of nationaltargets and the active dissemination of guidelines. Pay forperformance could result in a loss of the holistic approachto patient care,3 and patients with diseases that are not includedin the contract could be put at a disadvantage.3 Incentivesmay need to increase with time to maintain targets. Pay forperformance may be a good idea, but it should be implementedwith caution. We would recommend that when this approach isintroduced into a new area it be started as a pilot, so thatsome comparisons with conventional care as a control can bemade.
Abd A. Tahrani, M.D., M.R.C.P. Royal Shrewsbury Hospital Shrewsbury SY3 8XQ, United Kingdom abdtahrani{at}yahoo.co.uk
George I. Varughese, M.R.C.P. University Hospital of NorthStaffordshire Stoke-on-Trent ST4 6QG, United Kingdom
Andrew F. Macleod, M.D. Royal Shrewsbury Hospital Shrewsbury SY3 8XQ, United Kingdom
References
Epstein AM. Paying for performance in the United States and abroad. N Engl J Med 2006;355:406-408. [Free Full Text]
Chaix-Couturier C, Durand-Zaleski I, Jolly D, Durieux P. Effects of financial incentives on medical practice: results from a systematic review of the literature and methodological issues. Int J Qual Health Care 2000;12:133-142. [Free Full Text]
Roland M. Linking physicians' pay to the quality of care -- a major experiment in the United kingdom. N Engl J Med 2004;351:1448-1454. [Free Full Text]
The editorialist replies: I agree in general with Tahrani etal. As noted in my editorial, the findings reported by Doranet al. could reflect a number of different factors other thanimproved performance as prompted by the payment incentives.And surely there are a number of reasons to have modest expectationsfor the improvement in quality associated with pay-for-performanceprograms and to be wary of the potentially deleterious sideeffects they may inspire. There have been relatively few studiesof pay for performance in health care.1,2 On the whole, theirfindings are not encouraging, although most of the programsstudied may not be comparable to the large efforts now envisioned.Numerous pay-for-performance programs are under way in the privatesector, and although few have been formally analyzed, anecdotalinformation has not pointed to large negative consequences.Many aspects of pay for performance make intuitive sense. Thus,it seems to me to be reasonable to bolster efforts in this direction,so long as we maintain moderate expectations and monitor theprograms carefully, with an eye to making appropriate modifications.
Arnold M. Epstein, M.D. Harvard School of Public Health Boston,MA 02115
References
Rosenthal MB, Frank RG, Li Z, Epstein AM. Early experience with pay-for-performance: from concept to practice. JAMA 2005;294:1788-1793. [Free Full Text]
Rosenthal MB, Frank RG. What is the empirical basis for paying for quality in health care? Med Care Res Rev 2006;63:135-157. [Free Full Text]
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