Financial incentives for doctors don't always help

NEW YORK (Reuters Health) - Health systems haven't figured out how best to structure financial incentives to encourage primary care doctors to do their jobs better, suggests a new paper.

And it's not clear that the incentives, meant to reward doctors for improving patient care, always do more good than harm, according to Australian researchers who collected data from studies of incentive programs in the U.S., the UK and Germany.

In those studies, researchers looked to see if financial incentives made a difference in how often doctors screened for different diseases, referred patients to follow-up care or achieved a certain health outcome -- such as helping a patient quit smoking. Overall, the effects were mixed.

"Many doctors who already do well simply claim the money with no change in behavior," Anthony Scott, one of the review's authors from the University of Melbourne, told Reuters Health in an email.

"Incentives aren't often targeted at those doctors providing the poorest quality of care. And (sometimes) the amount of money may not be enough, or doctors simply aren't motivated by money by a great degree," he added.

He and his colleagues reviewed seven studies that compared doctors' performance before and after incentive programs began, or compared doctors in incentive programs with those just getting a regular salary.

Payments were set up in different ways: in one case, doctors got a small payment for each patient they helped quit smoking; in another model, clinics got one large payout after hitting a goal for the total number of patients referred to a quit-smoking helpline, then additional rewards for each extra referral.

Some of those incentives did seem to help. Clinics that didn't get incentives for referring smokers to a helpline sent about four percent of their patients there, for instance, while those getting rewarded referred 11 percent. But in other cases, the promise of a payout didn't mean doctors were any better at screening for breast cancer or Chlamydia.

Researchers have also struggled with how to reward primary care doctors fairly while taking into account many different measures of performance, said Jim Burgess, who studies health policy at Boston University and wasn't involved in the new review.

"There's the general problem around how you take an array of quality measures and try to work out a way of assembling the quality measures together and getting a comprehensive measure of performance," he told Reuters Health.

"Most of what's gone on beforehand (in studies) has really not generated what we think of as: 'We're really ready to go forward on this.'"

Some incentive programs may actually make certain doctors perform worse, or have no effect, he added. For example, in a program that ranks groups of doctors and then gives a payout to those who do the best on a certain measure -- one type of scheme he has studied -- "people who know they're not going to rank high, basically may not actually put effort into change."

Still, there are hundreds of different incentive schemes set up in the U.S. and Canada, Scott said. And one of the strategies in U.S. healthcare reform is to cut costs by rewarding doctors who perform well.

The researchers concluded in their report, published in The Cochrane Library, that more studies are needed to figure out how to make financial rewards pay off for patients and healthcare systems. For now, they said, any new incentive programs should be designed carefully -- and unintended consequences considered.

The idea, said Burgess, is "trying to take a wider view of the patient," using whole-patient health as the basis for rewarding doctors for good work.

SOURCE: bit.ly/q6Xn1I The Cochrane Library, online September 7, 2011.