Sunday, October 24, 2010

Pay for performance (P4P)-Goodhart's law aside is it unethcial?

This is a re-edited and lightly re-written version of a posting I made several years ago. Several years have passed and P4P has gone from a trial balloon to a more and more generally accepted fact of medical life, even though there continues to be cogent arguments in opposition to it and the broader bogus concept of "quality" measures.

Dr. Edmund Blum, an internist from Brooklyn makes the argument that pay for performance (P4P) involves a "irresolvable conflict " with the ethical standards of the medical profession.( American Medical News,Nov. 6,2006 issue in their "Professional Issue Section.) My bolding.


He says that P4P rests on 3 flawed premises or fallacies the most important of which is that P4P is consistent with medical ethics. He argues that it is not. (The other 2 fallacies are:P4P rests on a valid statistical foundation and P4P will improve the safety and quality of patient care). To those I would add a 4th namely that Goodhart's law would not be operable in the medical care setting.It has definitely been shown to operate there as well.

I quote:

"[medical] standards derive from a core of fiduciary responsibility, in which one person, the patient, depends on the superior knowledge and skills of another, the physician, and places complete confidence in that person in regard to a particular transaction-in this case, medical care."

"The fiduciary is held to a higher standard of legal and moral conduct and trust than a stranger or a business person...[This] obligates the physician to do his or her best for the patient regardless of reward.The duty goes beyond the 'due care' standard or tort law to a higher level of loyalty and commitment that is not contingent or rewards or penalties."

The idea of P4P involves an assumption that "the fiduciary relationship is insufficient motivation for the physicians to do their best."

To accept P4P is to accept the notion that physicians have not already been obligated to do their best for the patient and to place patient welfare above financial rewards and that they have to be giving a tip or a bribe to do their job. Dr. Faith Fitzgerald was on target when she said

" We must not servilely accept gratuities for doing our duty."

A few decades ago,I began the transformation from a lay person to a physician. Part of what was branded into my limbic cortex in that several year long process was the responsibility physicians have for their patients, a responsibility to do what is right for the patient,a responsibility to place their welfare above personal financial concerns. That responsibility cannot be canceled by a purported imperative to somehow also act as a steward of "society's resources" and work for social justice as the New Professionalism Charter implores.(See here for DrRich's comments on what that Charter has done to medical ethics).The prime directive was-and still should be- an individual physician's responsibility is to the individual patient .

The acceptance of P4P is so antithetical to the basic medical ethical tradition that I cannot believe professional organizations of physicians are supporting it, but they have -almost all of them have at least expressed written support. Tacit support of and advocacy for for P4P is equivalent to saying the ethics and culture of physicians are not adequate and to provide good clinical care it is necessary for third parties to proscribe behavior and reward and sanction accordingly. To sanction such thinking, in the words of Dr. Blum, is to "push us farther down the slippery slope to professionalization".

I am more pessimistic.We may already be at near the bottom of the slope and I see effort being made by relatively few physicians to try and climb back up.

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