Pay for Performance and Medical Professionalism

Health care delivery systems are widely studying and implementing physician pay for performance (P4P) initiatives to improve quality and control costs. However, the increasing focus on quality-driven financial incentives has some troubling implications for medical professionalism. This article examines the P4P concept in light of a notion of medical fiduciary professionalism that dates back to the 18th-century Scottish physician John Gregory. Gregory’s principles serve as a framework to assess the appropriateness of P4P initiatives in disseminating the principles of high-quality care without damage to professionalism, the patient-physician relationship, and access to care for all patients. Key words: physician incentive plans, professionalism I t has been widely documented that physiciansoften fail to implement even well-establishedand accepted recommendations for patientcare1,2; this failure in quality has the potential for real harm to patients.3 It is an ongoing challenge to the profession to continue to accurately define “qual-ity ” as it pertains to different patient populations and care settings and to determine novel mechanisms to educate and encourage individual physicians to pro-vide effective, high-quality care. Physician pay for performance (P4P) initiatives are being widely intro-duced and studied in this context; by linking physi-cian pay to some definition of high-quality care, they aim to improve health care quality while lowering costs.4 P4P concepts are being implemented with the collaboration of a wide variety of health care organi