Why Pay For Performance Will Never Work In Health Care

There is this concept in medicine called "pay for performance" where they link a portion of a physician's salary to how well his/her patients are doing.  They typically look at some measurable value such as percentage of patients who have controlled blood pressure or controlled diabetes.  If you have enough patients who meet the measures, you get paid extra.  If you don't then you don't get paid extra.  It is a simple concept and I understand its origins (there are a lot of doctors out there doing goofy stuff).  It is already being used in other countries with mixed results.  It will never work in American health care and here is why.

• a non-controlled diabetic no-shows a follow up appointment to discuss better ways to improve sugar control
• a non-controlled diabetic admits to taking their medicne on average every other day because they "can't remember"
• a new patient with markedly elevated blood pressure says "I'm not going to take medicine" before we even discuss treatment options
• A patient refuses to take a medicine due to things they've read on the internet but is willing to take a supplement for the ailment

 These are just some examples from the past week of things that I've had to deal with.  In the example of the blood pressure patient, I explain the known poor health outcomes of having prolonged hypertension, document that we discussed it and that they were unwilling to take medicine at this time, and move on with life.  In a pay for performance environment, I would have done the exact same thing and then promptly sent him a letter discharging him from my practice.  Who could afford not to?  As a physician I am in a position to offer advice that is based on my knowledge and health studies.  I cannot force people to do anything.  What they do with the knowledge and suggestions I make is completely up to them.  There are too many people out there who will believe the internet or something their grandma says before they'll take my advice.  There is no way pay for performance will work.  There will be too many people without access to health care.

On a completely unrelated topic, today is Anna Kournikova's birthday.  I believe she is 33 years old today.  I don't hear much from Ms. Kournikova these days.  She has done a pretty good job of staying out of the limelight.  I was a huge fan back in the day when she played.