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Financial incentives can worsen doctors’ performance

Experts claim schemes such as QOF can demotivate GPs

Adrian O'Dowd

Wednesday, 15 August 2012

Financial incentive schemes such as the Quality and Outcomes Framework (QOF) for GPs can undermine doctors’ motivation and worsen their performance, according to an editorial published online today in the BMJ.

Pay for performance schemes for health professionals “can undermine motivation and worsen performance” said US experts in the editorial who also claimed that gaming of the system was common.

Their views are published alongside an analysis of the positive and negative effects of financial incentives led by Professor Paul Glasziou of Bond University in Australia.

Professor Glasziou and colleagues said the current evidence on the effectiveness of financial incentives was “modest and inconsistent” and although reward schemes could sometimes improve the quality of clinical practice, they could also be an expensive distraction.

These schemes, however, have already been adopted as a key strategy by the NHS in the UK, Medicare in the USA, and many private insurers, based on the belief that people respond to rewards.

The 2004 QOF paid GPs in England up to 25% of their income for achieving 147 performance indicators, including 76 clinical targets such as recording smoking behaviour and keeping blood pressure and cholesterol levels below targets.

Whether the cost – around an extra £1bn annually – was justified has been contested, says the study.

The researchers devised a checklist to assess the potential benefits and harms of pay for performance schemes before they were implemented.

They said: “While some commentators and policy makers believe financial incentives can reduce the delay between new evidence and changes to clinical practice, there are many pitfalls. The proposed checklist is aimed at guiding implementers of financial incentives past some of these pitfalls.”

In the accompanying editorial, Professors David Himmelstein and Steffie Woolhandler from City University of New York and Professor Dan Ariely from Duke University in North Carolina argued that “questionable assumptions” underlying pay for performance schemes casted doubt over their clinical effectiveness.

They said: “Offering financial incentives to doctors, rather than enhancing their intrinsic motivation, may reduce their desire to perform an activity for its inherent rewards (such as pride in excellent work, empathy with patients).”

They were worried that pay for performance “may not work simply because it changes the mindset needed for good doctoring.”

However, they concluded: “If such schemes must be envisaged, it is essential that their likely benefit is rigorously considered before their implementation. Glasziou and colleagues’ checklist provides a salutary guide to such consideration.”

DOI: 10.1136/bmj.e5015
DOI: 10.1136/bmj.e5047

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