Impact of a pay-for-performance incentive on support for smoking cessation and on smoking prevalence among people with diabetes

The conclusions made in the “pay-for-performance” study recently published should be put into question, both the results and their consequences in the medical industry.

A pay-for-performance system for physicians in a public health system, such as that in Britain, allows otherwise (almost) equally paid doctors to earn more or less dependent on self-reporting. It is a horrible suggestion to recommend that Canada adopt such a pay-for-performance system. Wouldn’t it just be paying physicians for what they should already be doing – taking care of our health? Or even worse, paying them to ask certain questions but not others? (And, are M.D. graduates comparatively in need of financial gain?) Should we be paying for such a program? And, if so, how do we make sure the data collected is reliable? Although it might provide incentive for physicians to work harder, it is mostly just giving incentive for physicians to lie to the government, and drawing money away from other health services, in a healthcare system already declining, both in terms of care and cost? Sarcastically, it is asked, doctors, lying? Impossible – only patients do that. Why would we trust doctors to self-report any more than patients? Following Bhandari and Wagner’s 2006 study on self-reporting, depending on when and how doctors fill out their patient charts, there could be huge lapses in their files (1). This just confirms the idea that a medical license is really just a license to print money.

In this study, it should be noted that all the data obtained came directly from the physicians themselves, and that this is the same data reported to the government, so why shouldn’t doctors have an incentive to inflate their numbers to earn a premium? Furthermore, is it possible that truthful physicians who have been giving stop-smoking advice for years are just beginning to report it to look good in the numbers?

Besides, wouldn’t it be a better use of health resources to ask doctors not only to recommend quitting smoking, but also to warn teenagers, or all patients, not to take up smoking, because of its health risks, like is already done with sex? Or is this subject taboo? At least this would be original research (though not fit for Wikipedia), not just a test of someone else’s idea (2), a study that itself had many flaws.

Furthermore, as the authors noted in their conclusion, we cannot truly determine that the decrease in smoking is definitely linked to the increase in doctors’ scolding, especially considering that a large number of the patients whose smoking status was not recorded were probably non-smokers: why record a useless piece of data? (Do we need a checklist in the files? Hepatitis B, yes. Cholera, no. Smoker, yes.) Additionally, how thorough was the advice given by physicians? Surely some would just do it in passing, whereas others would give quite a convincing talk as to the health concerns of smoking.

Surely, however, the greatest incident in this study is the unusually high decrease in patients who identify as smokers from 2003 to 2005. According to Lancaster and Stead’s study (2), “the pooled effect of minimal intervention equates with a difference in the cessation rate of about 2.5% between those who received advice from a physician and those who did not.” However, this study reported an average decreased of 3.8% from smokers to non-smokers. A randomized control trial, the ideal of evidence-based medicine, would, if anything, have a higher rate of decrease than this study relying on doctors self-reporting in a pay-for-performance system. It merely emphasizes that an there existed an extremely high ratio of non-smokers to smokers in those patients who did not have their smoking status in their file.

This calls for the pay-for-performance system to have another requirement: you cannot begin to pay doctors for treating illnesses that a patient never had in the first place: there needs to be a standard amount of information in each patient’s file before doctors can be rewarded for a day’s work.

All the authors of this study can conclude is that there has been a very large increase in patients’ charts noting their smoking status, and that a pay- for- performance system is highly unreliable in data collection.

(1) Bhandari A, Wagner T. Self-reported utilization of health care services: improving measurement and accuracy. Med Care Res Rev. 2006 Apr;63(2): 217-35.

(2) Lancaster T, Stead LF. Physician advice for smoking cessation. Art. No.: CD000165. DOI: 10.1002/14651858.CD000165.pub2.

Conflict of Interest:

None declared