P4P and inequality

Pay-for-performance (P4P) is supposed to improve the health care quality for all. One may not be surprised if it were the case that more affluent, more educated individuals benefit most from P4P and thus existing health care disparities may increase. Author Lawrence Casalino and Arthur Elster, however, posit that P4P may actually reduce the quality of care that the poorest and sickest individuals experience. Why would this be? Here are some examples from their paper “Will P4P and quality reporting affect health care disparities“:

  • Reduction of physician income in poor, minority communities: The authors claim that doctors in poor communities will have less money for the IT, staffing and training needed to improve quality scores. When the doctors serving low-income households make less money, the supply of these doctors will inevitably decrease. Also, those doctors who decide to continue serving low-income communities may receive low P4P scores if patient compliance with physician recommendations is lower in poor communities. The low compliance rates could be due to language barriers, lack of education or lack of understanding of the doctor’s orders.
  • Teaching to the Test“: Doctors may preform services which evaluators deem important, but which in reality are less important to patient health in these under-served communities. “For example, with a relatively uneducated diabetic patient who speaks poor English, the physician might focus on making sure the patient has a hemoglobin A1c test (because this is measured) but not on the time-consuming task of explaining to the patient how to control his or her diabetes and blood pressure (because control of these things is not measured).”
  • Avoiding ‘problem’ patients: If there is no risk adjustment measure in the P4P compensation schemes, physicians who have healthier patients will score higher on all measures. Thus, physicians may have an incentive to avoid the specific patients they are supposed to help the most: the sickest. The authors write: “It is often stated, without evidence being cited, that patients’ characteristics do not affect physicians’ scores on process measures and therefore that process measures, unlike outcome measures, need not be adjusted for patients’ health status or socioeconomic status. To practicing physicians, this might seem implausible. For example, it should be easier for physicians who practice in affluent areas such as Marin County, California, than for those who practice in poor areas of Oakland to achieve higher rates of screening mammography: Their patients are more likely to be wealthy, well-educated, well-insured women who are aware of the benefits of mammograms, are more likely to request them, and are more able to travel to obtain them.