Pay for Performance - Short Take on Pay-for-Performance, Protocols, Evidence-Based Medicine

I keep six honest serving men
(They taught me all I knew)
Their names are What and Why and When
And How and Where and Who.

Rudyard Kipling, 1875-1936

What – Use of pay for performance, clinical protocols, evidence-based data, and value-based purchasing to meet management and outcome targets as means of judging and paying doctors for quality and minimizing practice variation.


Why - To establish criteria for clinical quality, standardize care, reduce practice variations, increase clinical outcomes, and decrease costs by using data to rationalize, manage, improve care, and cut costs by applying quality indicators to achieve managed care objectives – better care with lower costs.


When - These methods have been applied off and on over last ten years, with P4P being pushed with great vigor in last five years, particularly in hospital settings.

How - Both federal health agencies and health plans are advocating these various programs, ostensibly to increase quality, safety and transparency, reduce costs, and to better manage care.


Where – In most sections of country and especially wherever health plans are powerful, in states such as Minnesota, Wisconsin, California, and Massachusetts, but basically in all sections of the U.S.


Who - Health plan managers, Medicare and Medicaid officials, and executives in many health systems. Physicians resist because results and cost savings have been negative, modest, or not worth the expense. Complying represents a new practice burden, and clinicians fear data will be used against them. They are reluctant to accept the premise that third parties can judge clinical performance. Doctors assert personal and individual relationships between doctors and patients cannot be rated by retrospective data alone, and clinical decisions are difficult to judge without being present at the point of care. There are basically two schools of thought: P4P and related methods: 1) provide data to allow doctors to do well by doing good; 2) represent the practice of medicine bynother names.