I recently pointed to a BMJ study concluding that pay for performance doesn’t seem to motivate doctors.  It has been picking up steam in major media with TIME, for instance, saying, “Money isn’t everything, even to doctors.”

So much is riding on the concept of pay for performance, that it’s hard to fathom what other options there are should it fail.  And there’s mounting evidence that it will.

Aaron Carroll, a pediatrician at the University of Indiana, and regular contributor to KevinMD.com, ponders the options.

First, he comments on why the performance incentives in the NHS failed:

Perhaps the doctors were already improving without the program. If that’s the case, though, then you don’t need economic incentives. It’s possible the incentives were too low. But I don’t think many will propose more than a 25% bonus. It’s also possible that the benchmarks which define success were too low and therefore didn’t improve outcomes. There’s no scientific reason to think that the recommendations weren’t appropriate, however. More likely, it’s what I’ve said before. Changing physician behavior is hard.

So, if money can’t motivate doctors, what’s next?  Physicians aren’t going to like what Dr. Carroll has to say.   Sticks may have to be employed:

I actually think we need to use sticks as well as carrots.  We should stop reimbursing so much for stuff we’d like to discourage.

To put it another way, I think if we stopped paying so much for procedures, we would do less procedures.  But it you can make a lot ordering labs or make a lot not ordering labs, then why change behavior?

Here’s another way of looking at it.  If I can see 20 patients a day, and you offer to increase my pay 5% if I do an awesome job, I could work harder, hire people, and do QI to try and make 5% more.  Or, I could just see 21 patients a day.  Guess which I’ll do.  And the latter will increase costs.

Indeed.

We need to pursue a team-based approach to patient care, which Accountable Care Organizations and Medical Homes promote, and change the way physician practices are structured.  Physicians can’t do it by themselves.  Rather than punishing doctors, provide them with the necessary support staff to better manage chronic diseases and outreach to patients. And that’s going to cost money, at least in the short term.

Spending more money for better care is not a popular political stance these days, but it’s what needs to happen if we truly want better care for our patients.

Kevin Pho is an internal medicine physician and on the Board of Contributors at USA Today.  He is founder and editor of KevinMD.com, also on Facebook, Twitter, Google+, and LinkedIn.