Cardiologist-author Sandeep Jauhar with another excellent piece in today’s NY Times, where he eviscerates the P4P movement.

When non-clinical policy wonks try to regulate physician behavior, unintended consequences invariably arise. This often worsens the situation:

Whenever you try to legislate professional behavior, there are bound to be unintended consequences. With surgical report cards, surgeons’ numbers improved not only because of better performance but also because dying patients were not getting the operations they needed. Pay for performance is likely to have similar repercussions.

Jauhar points to the 6-hour antibiotic rule for pneumonia. Many patients are given antibiotics unnecessarily before a diagnosis is confirmed. This can lead to serious complications like C Difficile colitis – which happens to be on Medicare’s “no-pay” list.

Thus, physicians can be placed in a position where they are rewarded for giving antibiotics early, but penalized for the complications that arise from that incentive.

Also perplexing is who should receive the bonuses, as the average Medicare patient sees over five doctors annually:

Care is widely dispersed, so it is difficult to assign responsibility to one doctor. If a doctor assumes responsibility for only a minority of her patients, then there is little financial incentive to participate in P4P. If she assumes too much responsibility, she may be unfairly blamed for any lapses in quality.

The bottom line is that there is no evidence that pay for performance even works, and there is plenty of potential for patients to be harmed.

Medicine is highly nuanced, and what seems like a superficially good idea, often isn’t.