Stop penalizing physicians with pay for performance

Throughout my career, I’ve contemplated what it means to be a good doctor. While I still cannot fully articulate it, I know a good doctor when I see one. She’s the masterful diagnostician who can solve any medical mystery. He’s the physician-scientist who spends countless hours on finding a cure for HIV. She’s the colleague on my right, arguing on the phone with a patient’s insurance company to get a life-saving medication approved. He’s the colleague on my left who is running 45 minutes behind in clinic because he took extra time with a patient who was recently diagnosed with a terminal illness.

Recently, there has been a push by health systems to define what it means to be a good doctor by measuring physicians’ performance, value, and worth by “incentive quality metrics.”

These metrics are, in turn, tied to compensation. For example, each clinic within our health system chooses three metrics per year that physicians must meet; if they don’t meet the metrics, they do not receive 20% of their salary. Despite being called “incentives,” these are actually penalties that distract from improving patient care and promote physician burnout.

Case in point, at a recent clinic meeting, our group of providers got into a heated debate about which incentive quality metrics we should choose for the upcoming year. In the end, we ended up deciding on metrics that we knew everyone would easily meet (so no one would be financially penalized and could easily be measured (since we are not provided any additional support or resources to monitor these metrics).

I suppose I should be grateful that our health system allows us to determine which metrics we use instead of mandating them from the top down. But in the end, we chose metrics that are clinically meaningless, and that, most likely, will not improve the health of our patients. Moreover, we recently had two physicians (who unanimously are considered not just good but great doctors that medical students, residents, and fellows aspire to emulate) leave our practice. Both have been rated highly rated as “5-star physicians” in our practice and have received accolades for their accomplishments. Their decisions to leave were, in part, related to the culture created by our health system vis-a-vis initiatives such as the “incentive quality metrics.”

The scientist, the educator, and the perfectionist in me completely understand the importance and the need to measure and monitor our clinical performance and patient outcomes.

Physicians need feedback (especially constructive feedback) to improve. My issue with the current system is that these metrics are tied to the withholding of money and simultaneously called “incentives.”

The definition of incentive is “a thing that motivates or encourages one to do something,” also, “a payment to stimulate greater output or investment. “Withholding salary or putting salary “at-risk” unless certain outcomes are reached is not an incentive in my book.

I would much rather these tactics be referred to more honestly and transparently as penalties. And within these penalties lies an inherent mistrust of physicians. The message being sent is that health systems don’t trust physicians to take the best care of their patients as they possibly can. Instead, health systems feel a need to create often arbitrary or non-evidence-based metrics for physicians to either meet or be penalized (where’s the study that shows closing a patient encounter within 24 hours improved outcomes?).

There is little evidence that a pay-for-performance model, in which physicians are financially penalized, is effective.

A recent randomized controlled trial in JAMA Network Open showed that increased bonus size was associated with improved patient quality outcomes, but that loss aversion (e.g., withholding a portion of compensation) did not improve quality. As primary care providers, we are among the lowest-paid groups of physicians (versus hospitalists, procedural specialists, and surgeons, especially in proportion to the amount of time we spend caring for and doing work for our patients) and to suggest a penalty on our salaries is insulting.

Moreover, to require us to complete meaningless metrics is a waste of time, money, and effort. If quality metrics are to be tied to compensation, they should, at a minimum, be linked to bonuses and not penalties. Provide feedback for improvement but don’t link it to compensation.

I would argue that we should place more resources into optimizing systems that can help improve patient outcomes rather than penalizing physicians. We should provide physicians with a healthy practice environment that empowers them to be good doctors. Financial penalties are demoralizing, lead to burnout, and will continue to drive good doctors away. And that is something that health care and our patients cannot afford.