But in reality, there’s a dark side, according to a new editorial published in the British medical journal BMJ. The authors write that “a growing body of evidence from behavioral economics and social psychology indicates that rewards can undermine motivation and worsen performance on complex cognitive tasks, especially when motivation is high to begin with.”
A related article, also in the BMJ, proposes a checklist to try to guard against such distorted behavior.
In a joint news release, the authors say that while pay-for-performance is becoming widely adopted — in the federal Affordable Care Act, under Medicare and part of the new Massachusetts cost-cutting law — there’s little evidence that the practice is effective and it may in fact “do harm.”
Here’s the release, emailed to media by the single-payer advocacy group, Physicians For a National Health Program (which was co-founded by two of the editorial authors, Dr. David Himmelstein and Dr. Steffie Woolhandler, visiting professors at Harvard Medical School. They write that PNHP played no role in supporting their research):
The editorial, echoing a theme of the accompanying article, says there’s very little evidence that P4P has improved patient survival or any other measure of public health.
“Despite a dearth of robust evidence that P4P is clinically effective in health care, payers charge ahead with implementing everywhere an intervention that has proven to work nowhere,” the authors write.
Worse still, there is mounting evidence – reinforced by the latest findings in behavioral economics – that such schemes may actually do harm, the authors say.
For example, doctors and nurses may perceive detailed, overly prescriptive financial P4P contracts as “controlling,” which can cause them to dissociate from their work, lose their intrinsic motivation to do their very best for the patient, and engage in gaming – the medical equivalent of “teaching to the test.”
According to the authors, such gaming – e.g. “upcoding” a diagnosis to another condition that yields a higher payment – is already rife. For instance, labeling a pneumonia patient’s condition as “complex” rather than “simple” can increase the hospital’s payment by 42 percent. Continue reading