We dont need studies on whether P4P works. Just read these quotes!

By  |  May 19, 2014 | 


The United States does not possess sole propriety on P4P.  The NHS has been at the endeavor for years, with mixed results.

The NEJM released a short review, Successes and Failures of Pay for Performance in the United Kingdom, and after reading the author’s conclusions, one might wonder why we need more study. American exceptionalism aside, across the pond, the UK has done a portion of the scrubbing for us.

I mulled over an extensive  post, but given the P4P pearls below, I reconsidered.  I can’t best them, and reinventing the wheel seemed gratuitous.  I recommend reading them consecutively:

 –“After some years, the indicator [PQH-9] was dropped and was replaced by one that required physicians to record that they had completed a “biopsychosocial assessment,” without any specification of what such an assessment should contain. This meaningless indicator has also been dropped in the most recent changes to the framework. The message from this experience is that not everything that is important can be measured, and indicators should not be forced onto aspects of practice that are not easily measured — for example, mental health care and care of the frail elderly with multiple chronic conditions.”

–“There are substantial problems with linking patient-experience scores directly to physicians’ pay and this unpopular indicator [access to care] was dropped in 2011.”

“There is some evidence that, as in a previous incentive program in the United Kingdom, the Quality and Outcomes Framework has led to some adverse effects on the quality of care for medical conditions that are not included in the incentive program.”

–“As the percentage of physicians’ pay that is tied to performance increases (e.g., above 10%), the effect of the program is likely to increase, but so are the risks of unexpected or perverse consequences.”

–“From the start of the program, many observers had been concerned that physicians would “game” the system to maximize their incomes. It is likely that this fear has been realized to some extent”

–“Over time, however, the program became more intrusive into regular consultations with family practitioners. This was partly because the number of conditions in the framework increased to such an extent that nurse-led clinics could no longer be used for all the conditions that were covered.”

–“Although most family practitioners welcomed the initial pay increase, many of them began to resent the program as successive governments clawed back the initial large increases with a succession of below-inflation raises. The program was also resented by many nurses and salaried doctors who saw themselves contributing to income generation but not sharing in the benefits.”

If you oversee P4P, receive your salary based on P4P, or research P4P,  look at the review.  Yes, we can learn something from other countries.  Moreover, they can teach us the limits of payment systems–whose warts often lie below the surface–and whose impacts we must apply in metered doses and with a pragmatic touch.

I wish I had a dollar for every occasion a non-practitioner invoked P4P as a solution for our systems ills and to tame “unwieldy” physicians.  I would be rich.  Do me a favor and give them a copy of the commentary.  Also tell them that despite their use of the metric system, yes, the UK has hospitals, CT scanners, and lots of other neat stuff too.

Bob’s Your Uncle!

At top, scores plateau (“play to the measures”) and at bottom, measured patient experience  thwarted



***Finally, for an excellent take on P4P, I cant recommend enough a superb post from Health Affairs, Will Pay For Performance Backfire? Insights From Behavioral Economics.  The message will force you to rethink how we apply P4P in clinical care.


  1. […] Bradley Flansbaum thinks that maybe the P4P (Pay for Performance) train has lost its caboose. He points out that the P4P phenomenon isn’t an exclusively American idea: the Brits have […]

  2. […] posted on The Hospital Leader […]

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About the Author: Bradley Flansbaum

Bradley Flansbaum
Bradley Flansbaum, DO, MPH, MHM works for Geisinger Health System in Danville, PA in both the divisions of hospital medicine and population health. He began working as a hospitalist in 1996, at the inception of the hospital medicine movement. He is a founding member of the Society of Hospital Medicine and served as a board member and officer. He speaks nationally in promoting hospital medicine and has presented at many statewide meetings and conferences. He is also actively involved in house staff education. Currently, he serves on the SHM Public Policy Committee and has an interest in payment policy, healthcare market competition, health disparities, cost-effectiveness analysis, and pain and palliative care. He is SHM’s delegate for the AMA House of Delegates. Dr. Flansbaum received his undergraduate degree from Union College in Schenectady, NY and attended medical school at the New York College of Osteopathic Medicine. He completed his residency and chief residency in Internal Medicine at Long Island Jewish Medical Center in New York. He received his M.P.H. in Health Policy and Management at Columbia University. He is a political junky, and loves to cook, stay fit, read non-fiction, listen to many genres of music, and is a resident of Danville, PA.


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