Physician-level P4P--DOA? Can quality-based payment be resuscitated?

Unlike many areas of the economy where value is relatively easy to measure and reward, healthcare is "messy." Patients bring both clinical heterogeneity and illness-severity complexities to the interchange with their physician. The measurable outcomes or process measures are as likely to be due to patient characteristics as they are to be due to the actions (or inactions) of the patient's provider. Moreover, data suggest that the simplest fix for providers with bad metrics is to "dump" their sickest patients. Perhaps the most pernicious consequence of physician-level pay-for-performance (P4P) systems is how these systems can affect the neediest patients and their providers. As patient characteristics (eg, illness severity, preferences, resources) are more likely to be an issue in our poorer and minority communities, these patients' physicians will be at a financial disadvantage in a P4P system. It is likely that the widespread adoption of P4P systems will further limit these necessary resources.