Professor Steffie Woolhandler and colleagues from New York School of Public Health warned that such systems are based on ‘flawed assumptions about medicine, measurement, and motivation’. ‘We are worried that pay for performance may not work simply because it changes the mindset needed for good doctoring,’ they said.
Their comments came in response to a checklist developed by other researchers to ensure that financial incentives are not used inappropriately in healthcare, details of which have also been published in the BMJ.
In a BMJ editorial entitled ‘Why pay for performance may be incompatible with quality improvement’, Professor Woolhandler and her team said the evidence that financial rewards work in healthcare settings was ‘tenuous’.
‘The concept of pay for performance in healthcare rests on flawed assumptions about medicine, measurement, and motivation,’ they said. ‘Performance-based pay may increase output for straightforward manual tasks.
‘However, a growing body of evidence from behavioural economics and social psychology indicates that rewards can undermine motivation and worsen performance on complex cognitive tasks, especially when motivation is high to begin with.’
Professor Woolhandler and her team also said that the multiple indicators set out in QOF could weaken GPs’ drive to improve care.
‘Highly detailed prescriptive contracts may be perceived as controlling and may undermine the intrinsic motivation crucial to maintaining quality when nobody is looking,’ 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 added.
Professor Woolhandler and her team also pointed out that penalising poor performers financially would ‘can make matters worse’.