The American College of Physicians (ACP) says that pay-for-performance programs that provide incentives for good performance on a few specific elements of a single disease or condition may lead to better health care for some patients but can also have unintended consequences. Such plans may also neglect the complexity of patient care, especially for elderly patients and those with many chronic conditions.

ACP published a new position paper, "Pay-for-Performance Principles That Promote Patient-Centered Care: An Ethics Manifesto," in the Dec. 4, 2007, edition of its journal, Annals of Internal Medicine.

"Many of my patients have multiple medical conditions, such as high blood pressure, diabetes, arthritis, poor eyesight," says Richard L. Neubauer, MD, FACP, a clinical assistant professor of internal medicine at the University of Washington-Anchorage and chief of internal medicine at the Alaska Native Medical Center in Anchorage.

"Meeting specific performance measurements such as regular mammography screening may not be the best care for my 92-year-old female COPD patient with a myriad of other health problems. Or the care that she wants," Neubauer said. "But that may be the measure on which care is evaluated."

"In the effort to improve quality and control costs, we cannot lose sight of our primary professional commitment, which is to attend to our patients' welfare and best interests, including sensitivity to their preferences and life situation," said Neubauer.

Dr. Neubauer is a Regent of the American College of Physicians and an author of the new position paper.

The paper notes several possible unintended consequences of some pay-for-performance programs, such as an incentive to drop difficult patients whose outcome measures do not meet the quality standards or who cannot comply with treatment plans, or to not accept new patients who clearly will not meet existing measures.

The paper was developed by the ACP Ethics, Professionalism and Human Rights Committee and was approved by the ACP Board of Regents on Oct. 29, 2006. The paper published in Annals of Internal Medicine is based on a longer paper posted on the American College of Physicians Web site.

The paper complements two other position papers on pay-for-performance systems developed by the American College of Physicians: "The Use of Performance Measurement to Improve Physician Quality of Care" (2002, see here) and "Linking Physician Payments to Quality Care" (2005, see here ).

Annals of Internal Medicine is one of the most widely cited peer-reviewed medical journals in the world. The journal has been published for 80 years and accepts only seven percent of the original research studies submitted for publication. Annals of Internal Medicine is published by the American College of Physicians, the largest medical specialty organization and the second-largest physician group in the United States. ACP members include 124,000 internal medicine physicians (internists), related subspecialists, and medical students. Internists specialize in the prevention, detection, and treatment of illness in adults.

American College of Physicians