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If doctors are paid for performance, will some patients miss out? (croakey, opinion editorial)
02 June 2010.
The move towards paying doctors for performance, as announced recently in the Federal Budget around diabetes care, may have some unintended consequences, cautions AMA Victoria’s president, Dr Harry Hemley.
He writes:
“Last month’s Federal Budget confirmed the introduction of the voluntary patient enrolment scheme: From 2012 patients with diabetes will have the option of signing up to receive care exclusively from a clinic of their choice.
For the first time since 1 February 1984 some Australians will be seeing their family doctor without the right to a Medicare rebate. After 26 years, this universal aspect of Medicare is being eroded in favour of patient registration and paying for performance.
The government’s proposal just covers diabetics but the government has indicated this is a pilot program likely be expanded to encompass other chronic conditions in future.
General practice performance data will be compiled and clinics will be part, in part, on their ability to keep patients out of hospitals. It is unclear exactly what data will be collated and whether it will be used to compile league tables, like the My Schools website.
Pay for performance is not a new concept for Australian GPs. The General Practice Immunisation Incentive Scheme (GPII) was introduced in 1997 to reward GPs with bonus payments for childhood immunisation services. Since 1998, Medicare’s Practice Incentives Program (PIP) has been paying practice bonuses to thousands of Australian practices for meeting, or working towards, practice accreditation standards.
The difference between the existing programs and the diabetes plan is that under GPII and PIP, GPs are paid for providing services. Under the diabetes plan, the government wants to pay for patient outcomes, which won’t always reflect the quality of GP care.
Proponents of performance payments argue that the end result is the key. The object of health care is to make people healthier, so doctors should be paid for results. This was reportedly taken to the extreme by Arabian royalty in the middle ages, where the princes only paid their doctor when they were well. If they were sick, the doctor was not doing their job well enough to deserve reward.
Critics of paying for performance outcomes make the point that a doctor can recommend a course of action, but successful outcomes rely on the patient. For example, doctors are likely to recommend that all of their patients quit smoking, yet one in six adults still use tobacco on a daily basis.
There have been analyses of pay for performance regimes that have noted other possible deleterious effects. Pay for performance has been cited as:
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Encouraging doctors to avoid sicker patients who are less likely to achieve the outcomes.
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Causing doctors to neglect the types of care for which there are no reward.
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Increasing red tape, as reporting on performance takes time away from patient care.
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Decreasing internal motivation, as external motivation is imposed by the performance targets.
The AMA has put an alternative proposal for chronic disease management to the Federal Government based on the existing MBS structure and some key improvements. Under the plan, patients with chronic conditions would have access to a broader range of MBS-subsidised allied health services, and excesses of MBS red tape would be reduced.
Patients would not lose their entitlement to a Medicare rebate and doctors would care for patients based on their clinical needs rather than a pre-determined capped budget.”
• This is an edited version of a longer article.
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