Perils of Pay for Performance

Dr. Sandeep Jauhar wrote an essay this week in the New York Times about the perils of pay-for-performance (P4P). Specifically, Dr. Jauhar discusses how P4P may have unintended consequences and create perverse incentives due to poorly designed performance measures. The point is well taken, but it’s important not to confuse the merits of P4P with the measurement issues that exist.

With respect to the latter, back in my days as Director of Measure Development for the National Committee for Quality Assurance (NCQA), I co-authored a paper with Partners’ cardiologist Tom Lee, Jim Cleeman from NHLBI, and others working with us at NCQA on the development of new HEDIS cholesterol management performance measures. In the JAMA article, “Clinical Goals and Performance Measures for Cholesterol Management in Secondary Prevention of Coronary Heart Disease,” we tried (among other things) to communicate the difference between quality improvement measures and comparative performance measures.

Although the multi-stakeholder Cardiovascular Measurement Advisory Panel and NCQA’s measurement policy-making body, the Committee on Performance Measurement supported the goals of NHLBI’s practice guidelines, we believed that there are signficant differences “between a clinical goal for the management of individual patients (LDL<100 mg/dL) and a performance measure used to evaluate the care of a population of patients (LDL<130 mg/dL).” We described several reasons including: gaps in reasearch; drug efficacy; realistic performance measures; simplicity; and implications of physician failure.

Measurement systems designed for internal quality improvement may very well be different from those used to compare provider quality for a diverse population of patients, and we should make sure to consider the differences in establishing the criteria by which clinicians are compared and reimbursed.

However, we can make those distinctions and we need to in order to drive different kinds of quality improvement forward. If we don’t create fair measures that differentiate provider performance, we will continue to lack ways of adequately compensating those who deliver care for anything but the quantity of what they produce (i.e., number of services provided).

Joshua Seidman is the president of of the Center for Information Therapy
that aims to provide the timely prescription and availability of
evidence-based health information to meet individuals’ specific needs
and support sound decision making.

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Steve Beller, PhDIra BreiteMGrbar Recent comment authors
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Steve Beller, PhD

Superb discussion! Not only is there a big difference between measuring performance based on a population-based goals using generic guidelines and individual-patient-based goals using personalized guidelines, but our failure to collect and analyze hordes of detailed diagnostic and outcomes information on each patient means such personalized treatment is but a fantasy at this time. As I wrote two years ago, instead of our sledgehammer approach to care, we’d be wise to focus on establishing a precise scalpel-like approach to diagnosis and treatment planning. For example, we might find that a HemoglobanA1c of 7.5 is perfectly OK (and maybe even beneficial)… Read more »

Ira Breite

I keep thinking back to the cholesterol question. What qualifies action? Does telling a 35 year old non smoking male with an LDL of 140 to lose some weight and come back in 6 months count as much as throwing him on drugs? and what happens if (as is likely), it doesn’t work? PFP may very well lead to perverse incentives in a healthy population (ie it looks great for your numbers to statinize all these men). In sicker populations, the number of exceptions might be high. again, we, as physicians, do respond to economic stimuli (duh), and poorly done… Read more »


Agreed with Josh. While Dr. Jauhur raises plenty of valid issues with P4P (and other points including public reporting which is really a seperate issue), I kind of get the sense that he echoes the sentiments of alot of physicians who acknowledge their are issues with the quality of care in general but are very reluctant to give any real creedance to an externally imposed administrative/procedural responses to address these quality deficiencies. Physicians do need to be involved with the development, deployment, and feedback/improvement process (and are particularly with the measures being created) but not the days of not measuring,… Read more »


Doesn’t all this boil down to the difficulty evaluating quality of medical care? There usually are so many individual factors in a given situation that one size does not fit all. By that I do not mean that the quality of care cannot be assessed – it just seems to be much more work and more complex than looking just at a few indicators. What really could work is anonymous peer review. If you want to review a physician’s work, send a couple (maybe 5) anonymized notes to, say two physicians of the same specialty (that are deemed qualified for… Read more »