The Failure of “Pay for Performance”


In my previous post, I talked about the problems with using “evidence-based” medicine to constrain patient care and avoid dealing with the complexity of health care decisions. Physicians are perfectly capable of dealing with the complexity of their patients’ medical problems, but the Centers for Medicare and Medicaid Services (CMS) believe if care can’t be quantified on a check list, the care has no value. This means that physicians are not paid for thinking, but for doing.

Then the ungrateful checklist makers have the gall to complain that physicians “do” a lot of unnecessary procedures in order to increase their payments. No one bothers to notice that all these unnecessary procedures for most physicians are reimbursed at nickel and dime rates. Shocked? See “The Ubiquitous 1500 Claim Form and it’s Sidekick, the EOB” for some actual payments for primary care office visits.

Aaron Carroll, in “The Problem with ‘Pay for Performance’ in Medicine” investigates the “evidence-based” effectiveness how to improve patient care by incenting physicians to provide preventive care. On the surface, at least, this notion appears reasonable.

The idea behind pay for performance is simple. We will give providers more money for achieving a goal. The goal can be defined in various ways, but at its heart, we want to see the system hit some target.

The problem, of course, is how to quantify performance. CMS (and corporate medical entities) have a dismal record at failing to quantify what physicians do, but that’s a notion I have been writing about for a long time. Taking away the physician’s ability to make medical decisions and substituting a check list of payable “actions” does nothing to control health care costs and certainly has nothing to do with quality of health care. Just because the check list is labeled something like meaningful use or physician quality reporting system (PQRS) doesn’t impart anything meaningful or of quality to the list entries.

Aaron Carroll’s main point is that “Pay for Performance” has been around a long time and there have been numerous studies of the notion’s effectiveness. NONE of the studies indicated that paying for better results in patient outcomes accomplished much, if anything at all.

One of the reasons that paying for quality is hard is that we don’t even really know how to define “quality.” What is it, really? Far too often we approach quality like a drunkard’s search, looking where it’s easy rather than where it’s necessary. But it’s very hard to measure the things we really care about, like quality of life and improvements in functioning.


Complexity is difficult to turn into a check list. So someone should be asking the question as to why CMS, or any other health care entity, is still beating this dead horse.

But wait….then Aaron Carroll turns the discussion towards how hard it is to change physician behavior. Eh? Why are we worried about changing physician behavior. The focus should be on how to change the behavior of CMS, behavior which has been shown to produce no “evidence-based” results.

Further, Aaron Carroll draws attention to an article by the National Quality Forum which states:

The metrics chosen by Medicare for their programs included measurements that were outside the control of a provider.

So the question is why does CMS continue to pursue what does not work?

Instead of fixating on the difficulty of changing physician behavior, why are we not sending a clear message to CMS that the complexity of physician decision-making cannot be reasonably quantified (we have plenty of examples of unreasonable quantification).

It’s time to stop trying to control physician behavior with checklists and begin rewarding physicians adequately for providing quality patient care, whether or not that care is simple or complex, whether or not that care is “doing” or “listening,” whether or not that care can be represented with a checklist. The whole notion of “if you can’t see it, it doesn’t exist” is the basis of CMS checklists and resulting payments, and it’s a demonstrably ineffective way to define what is or is not quality health care.

Most physicians would simply like to take good care of their patients. With checklist mania, practitioners have to figure out how to provide needed care to their patients, much of which CMS refuses to pay for. This isn’t about changing physician behavior. It’s about confronting CMS with the utterly inappropriate ways CMS tries to control physician behavior with the express purpose of reducing the costs of health care. Labeling the checklist with some sort of adjective implying quality health care doesn’t change the real underlying motivation for the checklist. Or add to the “quality” of the care items in the list.

It’s time to start getting up close and personal about the difficulty in changing the behavior of CMS rather than the behavior of physicians.


Some young HR person once looked at my CV and asked me, quite seriously, if I had really done everything I had listed there. Well, yes. Because I am someone who can't sit in a Morris Miller cubicle every day, much less for any great stretch of time. Once the problem is solved, I get bored and I'm ready to move on to the next challenge. This hasn't afforded me any great stability in my work life. I simply arrive in places about ten years ahead of time. So far, at least, that penchant for early arrival hasn't been accompanied with a pocketbook full of door knobs.
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