Quality and Pay-for-Performance Does NOT Work!


For 13 years I have been saying that this Pay-for-Performance and Quality Metric trend was a scam.  It turns out I will keep saying it. Here is a great article in Modern Healthcare.  Please read it.  The ONLY ones left who believe in this crap are administrators.  Here are some highlights from the piece that you can chew on:

  • Linking financial rewards to cost-effective management of patient care or reducing adverse outcomes has not produced the desired results, recent studies show.
  • Poorly aligned monetary motivations can even lead to difficulties with staff recruitment or retention and lead to over-focusing on one specific issue at the peril of other, more important ones.
  • Value-based pay can drive healthy competition, but reliance on metrics that are easy to measure but don’t ultimately boost outcomes is “a clumsy response to fee-for-service.”
  • Advocates of quality incentive pay say the programs have lifted the performance of some physicians and improved collaboration among clinicians. That was the case for Fairview Health Services, which rolled out an ambitious compensation program in 2010 when it tied 40% of clinician pay to performance on a suite of metrics required by state law. Yet even with the promise of more money, the model “didn’t necessarily have an overwhelming impact,” said Valerie Overton, president for quality and innovation at Fairview Medical Group. It’s not that quality did not go up at all, she said. It’s just that it didn’t go up any more than market competitors that had not instituted such a program.
  • The Fairview payment model also was a source of “significant frustration” among staff, said Greene who, along with Overton, was one of the co-authors of the two studies on Fairview’s pay-for-performance effort.
  • In one, some primary-care physicians in New York were eligible to receive up to $200 per patient and up to $100,000 per clinic based on performance on evidence-based heart-care processes and outcome measures. But there were only small improvements despite the financial incentive, according to a 2013 report published in JAMA.
  • A program in which Houston clinics could receive twice the normal financial incentive given by Medicare for achieving cervical cancer screening, mammography and pediatric immunization targets also had little impact. “Despite considerable initial enthusiasm for the use of financial incentives for quality improvement, this study does not support the efficacy of this approach,” wrote the authors of a 2010 study of that program in the Journal of the American Board of Family Medicine.
  • Not surprisingly, when the CMS released its third year of 30-day readmission penalties last fall, quality researchers said that if only 769 of more than 3,370 U.S. hospitals succeeded in avoiding the fines, that program may not be achieving its desired goal of broadly improving quality of care.
  • “There is essentially no evidence that pay-for-performance works, and certainly no evidence that it works as it is being applied to American healthcare right now,” said Dr. Steffie Woolhandler, a professor at the City University of New York’s School of Public Health.
  • The tendency of pay-for-performance to “dangle money” before doctors has side effects. It turns the intrinsic professional and moral obligation of doing the best thing for the patient into a market transaction governed by price, and also requires excessive amounts of documentation and administrative costs. “If clinicians do have extra time, they should be focusing on real improvement and not just checking boxes to make pay-for-performance goals,” she said.

Years ago, I stated that Pay-for-Performance and Quality Measures was code for PHYSICIAN PROFILING.  I still agree with that moniker.  If you are stuck doing this charade then stop.  Fight back. You are helping no one but the administrators who want to get some gold stars from some bogus accrediting firm with four or five letters (PQRS, SHITE, DUMB, etc).  They want those gold stars for their resumes and to be promoted and have more adminibots under them.  Don’t let this happen.


Douglas Farrago MD

Douglas Farrago MD is a full-time practicing family doc in Forest, Va. He started Forest Direct Primary Care where he takes no insurance and bills patients a monthly fee. He is board certified in the specialty of Family Practice. He is the inventor of a product called the Knee Saver which is currently in the Baseball Hall of Fame. The Knee Saver and its knock-offs are worn by many major league baseball catchers. He is also the inventor of the CryoHelmet used by athletes for head injuries as well as migraine sufferers. Dr. Farrago is the author of four books, two of which are the top two most popular DPC books. From 2001 – 2011, Dr. Farrago was the editor and creator of the Placebo Journal which ran for 10 full years. Described as the Mad Magazine for doctors, he and the Placebo Journal were featured in the Washington Post, US News and World Report, the AP, and the NY Times. Dr. Farrago is also the editor of the blog Authentic Medicine which was born out of concern about where the direction of healthcare is heading and the belief that the wrong people are in charge. This blog has been going daily for more than 15 years Article about Dr. Farrago in Doximity Email Dr. Farrago – [email protected] 

  6 comments for “Quality and Pay-for-Performance Does NOT Work!

  1. MACF
    June 5, 2015 at 11:58 am

    To that you may add the effect of the rigged survey systems “approved” by the government in which by design 80% of hospitals will not get their retained Medicare/Medicaid money. That added to payments denied for readmissions, in hospitals infections and other items under “quality of care”.
    Administrators have not much to lose in this game. All they have to do is rank the providers in an organization by “productivity”, or worse, by ranks based on satisfaction surveys (some even based on less than 1% of the number of patients treated), and kick their asses at their pleasure.

    So much for Aldous Huxley’s vision of doctors being at the top of his futuristic society!

  2. Randy
    June 2, 2015 at 9:06 am

    Actually I think a lot of people believe in the concept of pay for performance. When someone says if doctors do a good job they should get paid a little more, that is intuitively going to make sense. That’s a big reason it will be tough to overcome this type of policy, even though as the article points out it doesn’t really work to improve quality. On a superficial level it sounds logical. If I start talking about the problems with collecting and communicating data in order to demonstrate quality, and that programs like PQRS might actually have a damaging effect on quality, most people’s eyes start to glaze over.

    My take is there is already pay for performance, since I’m a solo FP and if I don’t do a good job my patients will go see somebody else.

  3. Steve O'
    June 2, 2015 at 8:41 am

    But that cover rocks, man! Modern Healthcare is an actor who’s never seen an opthalmoscope, wearing a white coat. The girl is horrified – “I can’t bear to look at Modern Healthcare!” she looks away. The actor’s clumsiness and unfamiliarity embarrasses me as a tool-using mammal. And nobody in Modern Healthcare has a scintilla of familiarity with the process.
    Enough razzing the cover. The article is good. It quotes one of the perps of the process, Steffie Woolhandler.
    “If clinicians do have extra time, they should be focusing on real improvement and not just checking boxes to make pay-for-performance goals.” (Dr. Steffie Woolhandler, professor at the City University of New York’s School of Public Health) She’s one of the Leaders of the Revolution, and now she hints that it didn’t go all that swell. She has been an intellectual thug for twenty years, and now her crew is pissed off that bigger thugs have moved in and muscled her out of their sweet cash cow.
    She’s one of the Illuminati that laid down the principles of Modern Reform – doctors are greed-hogs snatching at the pennies – they need to be controlled and methodically ordered to do what the intelligentsia, in their wisdom, knows – Best Practices. Beat the sub-par until they come up to the “adequate” average of the LMD. (local MD). Honey, this is YOUR rodeo – ride the bull ’cause you started the show. But no, she scampers off to whine about the lesser quality of thugs that have taken the process over. Force voluminous amounts of irrelevant taskwork onto doctors, and that’ll keep them too busy to rip off the patient.
    And the doctors aren’t playing, and never did. Faced with these senseless games of three-card-monte, most of the doctors elect to retire out, or just let go. They don’t like the Emperor’s Clothes. Go figure.
    The only pay-for-performance that stands a chance of working is a “summary assessment based on experiential quality received by the individual patient.” That’s DPC. You have to trust that individual patients are brighter than sheep, and can tell the difference between sucky care and good care. The entire American Public Medicine movement insists that patients are dumber than sheep, and doctors pretty close – dumb AND greedy. And your brainchild’s loose on the American public, Steffie. Happy yet?
    It’s no surprise. Most revolutionaries turn surly when the pie doesn’t stay in the sky, and their brilliant plan turns out to obviously suck in a way that a third-grader could explain (see third grader on cover attempting to explain.) When all else fails, Beat the People (for their own good.) That’s so Twentieth Century – do we still need to act this way?
    The Big Brother of modern reform, the previous generation, was – ta-daaa! The Healthcare Maintenance Organization, birthed by Harvard in the 80’s and 90’s. How’d the HMO work out, kiddies? No?
    Whatever’s wrong with medicine, it’s not from the lack of Involvement by the Young and Arrogant, or of Bright Ideas to be enforced on the Ignorant Peasants. But insight never stopped the Truly Brilliant. God help us all.

    • Steve O'
      June 2, 2015 at 8:59 am

      Here’s some quotes from Daddy, Frederick W. Taylor, who came up with the conceptual axioms of this beastly method, “Scientific Management.” It was bad enough when it was used for industrial manufacturing – it led to riots in 1915 amongst the skilled workers at the Watertown Arsenal. But we are reforming the old “professional initiative and incentive” principles in Medicine to displace the people who actually do the job, with suits in Mercedes.
      “Under the management of “initiative and incentive” practically the whole problem is “up to the workman,” while under scientific management fully one-half of the problem is “up to the management.” ”
      “The (bad old) philosophy of the management of “initiative and incentive” makes it necessary for each workman to bear almost the entire responsibility for the general plan as well as for each detail of his work, and in many cases for his implements as well. In addition to this he must do all of the actual physical labor. The development of a (new modern) science, on the other hand, involves the establishment of many rules, laws, and formulae which replace the judgment of the individual workman and which can be effectively used only after having been systematically recorded, indexed, etc. The practical use of scientific data also calls for a room in which to keep the books, records, etc., and a desk for the planner to work at. Thus all of the planning which under the old system was done by the workman, as a result of his personal experience, must of necessity under the new system be done by the management in accordance with the laws of the science; because even if the workman was well suited to the development and use of scientific data, it would be physically impossible for him to work at his machine and at a desk at the same time. It is also clear that in most cases one type of man is needed to plan ahead and an entirely different type to execute the work. ”
      Look up Frederick W. Taylor: “The Principles of Scientific Management” for more of this sweaty bilge, and realized that Fascism is only practical principles of scientific management applied to the industry of governance. Pleez do read as much as you can stand. It’s the blueprint for what we see now, laid down 130 years ago or so.

  4. Perry
    June 2, 2015 at 8:27 am

    They are not measuring quality, they are measuring measurements.
    We are scrapping that horrible “fee for service” to pay doctors to tell patients they don’t need things, then penalize them if the patients get sick.
    Great system.

  5. RSWatkins
    June 2, 2015 at 7:51 am

    “The ONLY ones left who believe in this crap are administrators.”

    And those morons at the AAFP.

    Good post.

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