Pay for performance doesn’t work in difficult patient populations

Pay for performance.  It’s a lovely sounding concept. If you’re a good doctor, defined by having healthy patients who meet predetermined quality indicators, then you get paid more.

What could be simpler, right?


Not all patients are created equal.  Some are highly educated, highly literate, highly motivated to prioritize health.  They have good jobs with health insurance, so critical medical care isn’t prohibitively expensive. They don’t need to choose between paying out of pocket for $400 worth of necessary blood pressure medications or paying the rent.

And then there are my patients. Many are unemployed. Only a handful have private insurance plans.  Half are underinsured, with Medicaid or Medicare. Half are completely uninsured.  Only half speak English as a primary language. For the majority of my patients, housing is uncertain, jobs are not to be found, their neighborhood schools are struggling, and still my patients are human, living in bodies subject to human frailties.  They develop high blood pressure and diabetes and coughs and colds and prostate cancer and neurofibromatosis the same as anyone else.

A terrifying article (for those who take care of socioeconomically challenged patient panels) appeared in the Journal of the American Medical Association in September 2010.  A Harvard group led by Clemens S. Hong examined, as the title of the article spells out, the “Relationship between patient panel characteristics and primary care physician clinical performance rankings.”

They used data from 125,303 adult patients who visited one of 13 clinic sites linked by a common electronic medical system.  9 were hospital-affiliated practices, 4 were community health centers. 162 primary care physicians were ranked based on clinical performance scores.

Here’s the upshot: physicians whose clinical performance measurements ranked in the top tertile of the physicians, compared to the bottom tertile, had fewer minority patients, fewer non-English speaking patients, and fewer patients on Medicaid or without insurance.

This suggests to me that if your patients are English speaking, white, and well-insured, they’re going to understand what’s going on with them medically, easily access what they need to stay well, and be able to pay for the care you recommend.  You’re going to look good, and make more money for taking care of an easier-to-care-for population.

It doesn’t matter how good of a doctor you are if your patients are unable to follow your suggested care.  My patients skip specialty appointments because they don’t have a ride to the doctor.  They don’t take their insulin because our subsidized clinic pharmacy ran out and they can’t afford to pay full price in the drug store.  They take two of the same med because they can’t read the bottles and leaving the hospital they were given the brand name of the generic they take at home.

Adjusting for patient panel characteristics led to a relative mean change of 7.6 percentiles in physician rankings.  More than one-third of the primary care physicians (59/162) ended up in a different quality tertile, and would have earned different quality payments.

As a physician, I am rewarded on results, not effort. My patients, through no fault of my own, and really no fault of their own either, do not always take the steps I may recommend for them to be healthy and for me to attain all my quality indicators.  Luckily, I am meeting my pay-for-performance quality indicators (hooray for being rewarded for prescribing generic drugs!). But caring for difficult patient populations is a handicap for physicians in pay-for-performance incentive systems, potentially directing physicians away from caring for the populations who need our care the most.

Kohar Jones is a family physician who blogs at Progress Notes.

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  • Norman Beaudoin

    The same can be said for inner city schools.  If you have students that don’t care, parents that don’t care, what is a good teacher going to accomplish?

    • Ybi Girl

      But, as one who teaches in one of THOSE schools, when you raise the bar, be ready to raise it again. I see no difference  in the intellectual capabilities of my under-served students and my Ivy League graduate classmates. It is all a matter of challenge and expectation. I expect the BEST and my students rise to the CHALLENGE.

      I love my job. And, that is all you need to know.

    • Medical apps

      I totally agree with you Norman.

  • Joanna Davies

    Please pass this along to your patients, your physicians, your representatives in Washington and your family. Medical care is no longer in the hands of physicians and patients; it belongs to insurance companies and bureacrats. Those of us who care for patients who are poor, not English speaking, underinsured do our best. I am sorry for the younger generation of health care providers.

  • Ybi Girl

    When are you willing to PAY YOUR PAITENTS??? That is when pay for performance will work. Let them know how their co-pay will decrease when their health indicators increase…oh, wait You mean insurance companies aren’t incentivising their patients? Shocking …LOL.The whole system needs revamping!

  • Anonymous

    Perhaps I am missing something, but I’ve always assumed that the whole point of PFP in education and healthcare and such is not to be fair but rather to save money so as to lower tax on the wealthy, all the while decreasing the incentive to help the poor and otherwise vulnerable, about whom policy makers in this country care not one whit anyway. If you want fairness, you’re in the wrong country. 

  • Anonymous

    Please make sure to fact check this statement:  PFP does not work!!!  In case you missed it, the British Medical Journal issued a study on 500k patients over 7 years. PFP did not move the needle on outcomes!!

  • John Kaegi

    PFP viewed in that “traditional” context, I agree with you too.  However, PFP can be simplified and constructed in a way to be a win-win-win for all (provider-patient-organization).  Think of it like an insurance pool where the good risk and the bad risk are pooled together to create an average risk.  An average health quotient can be calculated for the doctor’s patient panel, which can be the baseline for PFP.  Then, PFP is based on improvement of the average health quotient of the patient panel.  Any average can be improved regardless of socioeconomic profile.  The doctor is rewarded for improving the panel’s health, not any one individual within it.  Now, think about using a different compensation scheme, rather than FFS with its hassles, denials, recodings, etc.  Pay a salary plus a liberal upside bonus for panel health improvement and you have greater opportunity for economic gain with fewer hassles and a focus on wellness.  That’s how its done by Healthstat for its employer clinics.  It can be duplicated for general practices as well as long as the revenue generated by a patient panel is pooled to create a basis for paying fair salaries.

    John Kaegi
    Chief Strategist

  • helena kryuchkin

    Dear Dr. Jones, THANK YOU for stating what I deem to be a pretty obvious problem with the proposed systems of payment.  I work in a non-clinical capacity at a hospital and am terrified of the idea that our patients’ compliance with orders will determine the reimbursement.  I have interacted with patients that you describe, as well as those who are of the “educated, Caucasian, fully insured” variety who consciously choose NOT to comply.  They have their reasons, most of which seem absurd to the clinicians whose orders the patients ignore.  The issue with the various systems of payments that are up for consideration is that they put the onus on the providers and not on the patient.  At what point will the patient be held accountable for the decisions that are made?

  • Anonymous

    Thank you all for your great comments–
    I love the idea of paying patients to be well–now THAT makes sense
    And the idea of paying physicians based on health *improvement* in the average health quotient of a given patient population.
    Systems do need to change.
    There are fascinating parallels between paying teachers and physicians for performance.
    In both cases, it’s easier for the teacher or provider to hit goals if they’re working with an “easy” or “good” group.
    But those aren’t the populations who can most benefit.
    I like the idea of challenging our patients to be well–and to reward them in concrete ways for taking care of themselves.  How awesome would it be to have health insurance companies pay patients for performance?  $20 to take all their meds.  $10 per pound of weight loss. $5 per pound to maintain it over two years.
    Then I’d bet we’d start seeing some major changes in health outcomes!
    How would we make this work, though?

  • Anonymous

    All good points, but some of the problems that physicians have with PFP systems are self inflcted. Hiring medical assistants instead of nurses limits the practice’s ability to conduct educational efforts with their patients. Yes, RNs and LPNs cost more, but they also have the ability (and professional obligation) to provide education for their patients on such useful topics as nutrition (e.g. why going home and eating french fries is not the best idea after discharge from an admission for congestive heart failure, etc.,) medication administration, and other wellness issues. Physicians are notoriously bad on  followup of patients after hospital discharge and for failing to work with insurance and hospital case workers who are trying to address the indigent populations. There are programs out there to get your patients to your office, and to pay for their prescriptions, but many of those programs count on your (even passive) support, and too often they don’t get it.

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