Survey: Physicians support pay for performance but oppose public reporting

Doctors worry that such programs may harm poor and non-compliant patients

March 6, 2007

Although three out of four primary care doctors support the use of financial rewards as an incentive for better medical care, most of these physicians oppose public reporting of such quality assessments at the individual or group level, report researchers from the University of Chicago in the March/April issue of Health Affairs.

Physicians surveyed for this study had two chief concerns. Fewer than one-third of them believed that current quality measures were up to the task; only a little more than one-third were convinced that health plans and the government would "try hard to make such measures accurate." The physicians also worried that both pay-for-performance and public-reporting programs could cause doctors to shun sick, poor or non-compliant patients and to neglect un-measured but equally important areas of quality.

"We found a sizable reservoir of potential physician support, in principle, for financial incentives to improve care," said study author Lawrence Casalino, MD, PhD, assistant professor of health studies at the University, "but we also found a good deal of mistrust and concern about how such incentives would be assessed and applied and how the applications might alter access to care for high-risk or disadvantaged patients."

"Like managed care," the authors note, "these programs can be implemented without physician support. However, implementation without at least some degree of support risks a backlash from both physicians and patients."

The researchers surveyed 1,168 randomly selected general internists. Almost half (48%) completed the seven-page questionnaire.

The most striking discovery was the large gap between substantial support for financial incentives to improve quality and the widespread opposition to public reporting, which was seen by doctors as potentially punitive. "To our knowledge," the authors note, "this is the first survey to report this gap."

Less of a surprise was the pervasive lack of confidence in the ability to assess quality of care--doubts that "are supported in the literature," the authors note. Eighty-eight percent of respondents questioned the accuracy of current tools for risk adjustment; 85 percent did not think that socioeconomic status was adequately considered, and 82 percent worried that flawed quality assessments would encourage physicians to avoid high-risk patients.

"I have 10-15 patients whom I would have to fire," penned one respondent. "The poor, unmotivated, obese, and noncompliant would all have to find new physicians."

These concerns, if not addressed, could quickly undermine physician support for pay for performance, said Casalino. Among the survey's findings:

• Almost three-fourths of respondents agreed either "strongly" (32%) or "somewhat" (41%) that "if the measures are accurate, physicians should be given financial incentives for quality." However, only 30 percent of respondents agreed strongly (4%) or somewhat (26%) that "measures of quality are [currently] generally accurate." There was little confidence that this would change.
• Only 38 percent agreed strongly (5%) or somewhat (33%) that "health plans will try hard to make quality measures as accurate as possible;" only 35 percent agreed strongly (5%) or somewhat (30%) that the government would do so.
• Only 32 percent of responding internists strongly supported (5 percent) or somewhat supported (27 percent) public reporting of individual physicians' quality scores, and only 45 percent agreed strongly (8 percent) or somewhat (37 percent) with public reporting on the medical group level, even if the measures involved were accurate.

This is a key moment for such projects, the authors conclude. Although such programs are proliferating, "their features are not yet locked into place. Giving serious consideration to physician views might help policymakers design programs to have as positive an effect as possible on the quality of health care."

The Chicago Center of Excellence in Health Promotion Economics and the U.S. Centers for Disease Control funded the research. Additional authors include Caleb Alexander, Lei Jin and Tamara Konetzka of the University of Chicago.