Maybe pay for performance can be smarter

I’m a well-documented skeptic about pay for performance. Ashish Jha and Aaron McKethan are trying to change my mind:

Over the past decade, public and private payers have experimented with the use of financial incentives to motivate physicians to achieve quality and efficiency. The idea behind pay for performance is simple. Because individuals and organizations respond to incentives, physicians whose patients achieve desirable outcomes should be paid more as an incentive to improve their performance. Yet the results of pay-for-performance programs have been largely disappointing. One argument is that neither the right set of incentives nor the right set of metrics has been identified. Another explanation, which has received far less attention, is that the right set of patients has not been identified for targeted efforts.

You really should go read the whole thing. The gist of what they suggest is that instead of setting benchmarks for the population, many of whom already may have met them, we should identify – locally – patients who are performing poorly, and then incentivize doctors to do a better job of caring for them. The bonuses per patient would be higher, but the system would be more efficient, because new investments would be made on the patients who need improvement the most.

It’s a compelling idea. Especially since, as we know with wellness programs, things like this seem to work better when they’re targeted to the people who need help, not everyone in general. My one concern is that this isn’t policy, as much as it is a suggestion for local payors and practices to make changes themselves. I’m all for that, but the ACA and CMS do seem to like to keep things at a national level…


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