Web-Based Discussion on P4P
March 19-30

As the pay for performance (P4P) phenomena continues to grow, a serious economic critique is due. A collaboration of health economists have recently called for the contextualization of P4P in a theoretical framework informed with knowledge and experience from outside of the health care realm as well as the need for research. During this Web forum, we will be discussing (1) the econometric perspective of P4P, specifically the issues surrounding agency and professionalism and (2) whether P4P allocations by third party payers are efficient and/or equitable when the entire population or risk pool is considered.

Agency

P4P is possible in part because purchasers believe they now have adequate clinical information to monitor and pay for processes and outcomes performance. They have chosen areas such as prevention and chronic illness care where the type of population-based evidence base allows them to embark on this path. How far can paying for process and outcomes continue before they confront areas where clinical decision making is fraught with uncertainty, such as in diagnosis and complex case management and/or where hard to measure patent factors play a central role in determining process and outcome? Is it in the interest of patients for the physician to be rewarded for and therefore expect them to comply with recommended care when the opportunity cost for the patient is too high? In separate surveys, results have detected a lot of physician concern with potential “conflict of interest” with P4P and the related fear that the dumping of difficult to treat patients by medical doctors is around the corner. Is P4P a threat to the role of the medical doctor as a trusted agent when the patient is the considered to be the principal, a threat to the part of the medical profession that serves a useful role in society (distinguished from the possibly larger part that serves primarily the profession), and the objectives of third party payers even when one considers them to be the principal?

Efficiency and Equity

What is the marginal utility of investing in getting the next diabetic patent in for care as one moves up the performance curve? What does the marginal cost-utility curve look like? Where could those resources have been “better” spent by a third party payer? Will P4P exacerbate rather than reduce disparities because it provides incentive to focus on “compliant” patients or to design interventions and disease management programs to target “easiest-to-improve” populations?

Moderated by Karen Eggleston, Ph.D., the interest group will be discussing these and other aspects of P4P. To participate in the discussion, please visit the Interest Group's Web Forum.