General health checks in adults for reducing morbidity and mortality from disease

By Lasse T Krogsbøll, Karsten Juhl Jørgensen, Christian Grønhøj Larsen, Peter C Gøtzsche
The Cochrane Library, October 17, 2012
Plain language summary
General health checks involve multiple tests in a person who does not feel ill with the purpose of finding disease early, preventing disease from developing, or providing reassurance. Health checks are a common element of health care in some countries. To many people health checks intuitively make sense, but experience from screening programmes for individual diseases have shown that the benefits may be smaller than expected and the harms greater. One possible harm from health checks is the diagnosis and treatment of conditions that were not destined to cause symptoms or death. Their diagnosis will, therefore, be superfluous and carry the risk of unnecessary treatment.
We identified 16 randomised trials which had compared a group of adults offered general health checks to a group not offered health checks. Results were available from 14 trials, including 182,880 participants. Nine trials studied the risk of death and included 155,899 participants and 11,940 deaths. There was no effect on the risk of death, or on the risk of death due to cardiovascular diseases or cancer. We did not find an effect on the risk of illness but one trial found an increased number of people identified with high blood pressure and high cholesterol, and one trial found an increased number with chronic diseases. One trial reported the total number of new diagnoses per participant and found a 20% increase over six years compared to the control group. No trials compared the total number of new prescriptions but two out of four trials found an increased number of people using drugs for high blood pressure. Two out of four trials found that health checks made people feel somewhat healthier, but this result is not reliable. We did not find that health checks had an effect on the number of admissions to hospital, disability, worry, the number of referrals to specialists, additional visits to the physician, or absence from work, but most of these outcomes were poorly studied. None of the trials reported on the number of follow-up tests after positive screening results, or the amount of surgery used.
One reason for the apparent lack of effect may be that primary care physicians already identify and intervene when they suspect a patient to be at high risk of developing disease when they see them for other reasons. Also, those at high risk of developing disease may not attend general health checks when invited. Most of the trials were old, which makes the results less applicable to today’s settings because the treatments used for conditions and risk factors have changed.
With the large number of participants and deaths included, the long follow-up periods used in the trials, and considering that death from cardiovascular diseases and cancer were not reduced, general health checks are unlikely to be beneficial.
Abstract:
http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009009.pub2/abstract
And…
Comment on this study by H. Gilbert Welch, MD, The Dartmouth Institute, Community and Family Medicine
I think that there has been a growing realization that we’ve oversold the value of screening for early cancers or early disease, that we sort of suggested that there is considerable benefit when, in fact, the evidence about benefit is at least open to question. It’s not a huge benefit. And we’ve downplayed or ignored entirely the downsides of the problem. I’m not saying there’s one right answer, but I am saying that there are two sides to the story. And I think that there is a growing realization that there are benefits – that everyone knew – but there are also harms, and people have to balance those.
Video of Dr. Welch’s response to the Cochrane study:
http://www.medpagetoday.com/PrimaryCare/GeneralPrimaryCare/35356

General health checkups or routine physicals have been a mainstay of keeping people healthy, or so we thought. Finding disease early and providing appropriate interventions seems like a recipe for success in maintaining health. However, because some doubts have arisen over this concept, The Cochrane Collaboration studied randomized trials of health checks and found that “general health checks are unlikely to be beneficial.”
Though this study does indicate that the formal health check is unlikely to be beneficial, does that apply to isolated procedures such as blood pressure checks, serum lipid screening, cervical cancer screening, or skin screening for melanomas? Numerous studies have suggested that early intervention is effective in these disorders. If not, then it wouldn’t be logical to treat hypertension, hypercholesterolemia, or most early cancers, yet we do it all the time.
H. Gilbert Welch, MD, co-author of the enlightening book, “Overdiagnosed – Making People Sick in the Pursuit of Health,” provides perspective in his comments on the Cochrane study. He says that we need to balance the benefits “that everyone knew” with the harms that interventions can cause.
It seems that rather than promoting general health checkups as an isolated process, we should use this information to promote primary care. Establishing a long-term relationship with a primary care professional or team can provide continuity in health screening procedures, both in their timeliness and appropriateness.
What does this have to do with single payer reform? Simply that the single payer model includes reinforcement of our primary care infrastructure as an important and effective means of providing higher quality and less costly care for everyone.

Transforming Medicare into a Premium Support System: Implications for Beneficiary Premiums

By Gretchen Jacobson, Tricia Neuman and Anthony Damico
Kaiser Family Foundation, October 2012
Over the past several decades, the idea of transforming Medicare from its current structure to one known as “premium support” has been raised intermittently as an approach for reforming the Medicare program, often in the context of efforts to reduce the federal debt and deficit.  The primary goals of a premium support system are to reduce the growth in Medicare spending, and rely more on a competitive marketplace.  While the parameters of various premium support proposals differ, the general idea is for the federal government to make a predetermined contribution on behalf of each person on Medicare that would be applied toward the premium for a health insurance plan.
This paper aims to help inform policy discussions by examining the potential implications of a leading premium support approach on Medicare premiums, the extent to which Medicare premiums would vary by state and by county, and the key factors that could drive variations in premiums under this approach.  The analysis looks at an approach to premium support that ties federal payments to the second lowest cost plan offered in an area or traditional Medicare, whichever is lower.  This approach is similar to the premium support proposal included in Chairman Paul Ryan’s (R-WI) budget proposal for FY2013 that was embraced by Presidential nominee Mitt Romney, and previously included in the Wyden-Ryan and Domenici-Rivlin proposals.  The study focuses on beneficiaries’ Medicare premiums, but does not take into consideration out-of-pocket spending due to the effects of changes in benefits, cost-sharing requirements and premiums for supplemental insurance.
From the Discussion
These findings underscore the potential for highly disparate effects of a premium support system for beneficiaries across the country.  The results show how individual decision making (plan choices), coupled with geographical variations in the cost of traditional Medicare and the private health plans, would play a major role in determining how well beneficiaries fare with respect to premiums under this approach.
The study estimates that the majority (59%) of Medicare beneficiaries would be expected to face additional premiums, based on current plan preferences, under the modeled premium support system.  Clearly, a smaller share of beneficiaries would pay higher premiums if they instead enrolled in a low-cost plan offered in their area.  In high-cost areas, such as Miami and Los Angeles, most beneficiaries in the traditional Medicare program would see a significant increase in Medicare premiums, unless they opted to enroll in a lower-cost private plan.  Conversely, in low-cost areas, such as Honolulu County in Hawaii and Multnomah County in Oregon (which includes Portland), the majority of beneficiaries would not pay additional premiums if they remained in their plan (based on current enrollment in that county), but a sizeable minority (17% and 43%, respectively) would pay at least $100 more in monthly premiums for their Medicare coverage in a private plan.
Further, this analysis shows that premiums for traditional Medicare would likely vary across states, and within states, by county.  If this system had been fully implemented in 2010, some would have paid the same Medicare premium, while others would have paid an additional $200 more per month in Medicare premiums, not considering other additional costs beneficiaries could potentially face, such as cost-sharing requirements for benefits covered by the plan, the cost of benefits not covered by the plan, and premiums for supplemental insurance.
Beyond premiums, other factors could be considered in choosing a plan, which may or may not be consistent with the choice of a low-cost plan.  First, enrolling in a low-cost plan, if it requires changing from another plan, may require beneficiaries to change their doctors and other health care providers, posing potential problems for beneficiaries with long-standing relationships with their doctors, especially those with chronic conditions.  Second, some beneficiaries may value the option to enroll in a highly-rated plan, but quality is not a factor in determining which plan is the benchmark plan.  Third, low-cost plans in a given area may or may not have the capacity to accommodate all beneficiaries who wish to enroll in the plan. Fourth, the low-cost plans offered in an area could change each year or so, as has occurred in the Medicare Part D program, potentially creating instability for beneficiaries with modest incomes who would have a strong financial incentive to remain in a low-cost plan each year.
Given a lack of specificity about some of the key policy elements and questions about the likely response of the insurance industry and beneficiaries, there remains great uncertainty about the expected effects of this approach for elderly and disabled Americans in the future.
Limitations
* This study focuses narrowly on the expected effects of a premium support system on beneficiaries’ Medicare premiums – an approach that excludes the effects of changes in benefits, cost-sharing requirements and premiums for supplemental insurance.
* This study models the effects of a premium support system in a given year, but not the expected costs for beneficiaries over the longer term, including the effects of adverse selection for beneficiaries in traditional Medicare or the potential for Medicare spending caps to increase premiums for beneficiaries over time.
* This study does not examine the effects of a premium support system for beneficiaries with low-incomes, including dual-eligible beneficiaries who could also be affected by changes made to Medicaid, such as a Medicaid block grant.
* This study considers potential changes in plan behavior (changes in bids), but does not analyze the potential for insurers’ responses to vary, based on local market conditions.
* This study does not capture the nuances of beneficiaries’ plan switching behavior and only allows for beneficiaries to switch into a benchmark plan, rather than a plan that is less expensive than their current plan, but is not a benchmark plan.
* This study does not consider whether benchmark plans (if not traditional Medicare) would have sufficient capacity to serve all potential enrollees.
* Finally, this analysis does not consider the effect of a premium support system for other payers, including the federal government, state governments (Medicaid), or employers.
http://www.kff.org/medicare/upload/8373.pdf

When reforms for health care are proposed, the first response by many is, what will it cost me? In the case of the premium support model (voucher, or defined contribution), most people want to know what the premium will be. This meticulous 48-page study by Kaiser Family Foundation shows that for the majority of individuals, premiums would increase. But there is much more to premium support than merely the premium to be paid.
Reading the full report might be of interest to individuals who would want to see the complexities involved in simply determining the impact on premiums. In the excerpts above, some of the factors that were not considered are emphasized, especially in the list of limitations of the study. Because the proposal depends heavily on private insurance plans, there are a slew of potential negative impacts which can increase costs and impair access for the Medicare beneficiary – impacts that are far beyond those suggested by the list of limitations.
If you aren’t convinced by now that premium support is a terrible idea, go to our website at www.pnhp.org and type in “premium support” in the search window and spend a an hour or so reading what we have to say. Then go back and read what Romney and Ryan have to say, and you’ll see what they deliberately left out. It is a scheme to slowly unwind the social contract of health care justice, when what we need to do is to improve that contract and expand it to cover everyone.

Physician advocacy: for patients and for social change

By Josh Freeman
Medicine and Social Justice, October 13, 2012
A recurring question for physicians and others in the health profession is what degree of health advocacy is expected or appropriate. For those of us in medical education, the question becomes how much of the training (and evaluation) of medical students and residents should be based on advocacy for their patients or populations.
In the United States, the clearest expression of the role of advocate is in the American Medical Association’s (AMA) Declaration of Professional Responsibility: Medicine’s Contract with Humanity, which contains, as item #8, “Advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”
Dobson and colleagues propose a parsing of the concept of advocacy into two components. They call these “agency”, working on behalf of the interests of a specific patient, and “activism”, which is more directed toward changing social conditions that impact health, and whose effect is seen on populations more than individuals.
They note that “…several studies have concluded that although physicians generally endorse the idea of advocacy, they rarely engage in it.” They summarize the difference between agency and activism by saying “…whereas agency is about working the system, engaging in activism is about changing the system.”
There are, however, many physicians who do act as social activists, and we need more of them. The source will be medical students who then become residents. Luckily, there seem to be no shortage of entering medical students with this commitment. They demonstrate it by community volunteer work, creating and working in free clinics, volunteering their time to work in schools, and pursuing training in public health, public policy, and community involvement. Sadly, however, along with empathy, which has been shown to dramatically drop as medical students enter their clinical training (Hojat, et al.[2], and this blog, “Are we training physicians to be empathic? Apparently not.”, September 12, 2009), so does volunteerism and commitment to social change.
When we look at the American political landscape, we see a fair number of physicians involved in politics. It could be argued that, in these roles, they are advocating for social, economic, educational, and political changes. What is disconcerting is that the majority of these physician politicians seem to ignore the second half of that sentence, “…that ameliorate suffering and contribute to human well-being”. They are often found among, and sometimes as leaders, in advocating policies that slash the social safety net, decrease funding for public education, and oppose universal health insurance. Too frequently, they act as agents of their own social class than as advocates for those most in need.
That doctors will most often adopt the “agency” role when it comes to issues that most directly affect the health of their patients, that can be arguably seen as “medical”, is very reassuring.
The advocacy role is more complex. Not only are many physicians socially conservative and not, perhaps, in support of policies “…that ameliorate suffering and contribute to human well-being,” physicians are busy people who mostly see themselves in the role of providing direct patient care, not advocating for systemic societal change.
I would like to think that all physicians manifest advocacy in the “agency” sense for their patients. It may be wishful thinking to hope that all physicians will manifest advocacy in the “activist” sense, that they will fulfill the AMA’s Declaration by actually advocating “…for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.” But if we do not make this a core value for physicians that is ubiquitously taught in medical school and residency, if we do not select students because of their commitment to advocacy, we will have much less of it.
And we need it badly.
(Joshua Freeman, MD is Chair of the Department of Family Medicine, University of Kansas Medical Center. These excerpts are from his blog and do not represent the views of the University of Kansas.)
http://medicinesocialjustice.blogspot.com/2012/10/physician-advocacy-for…
And…
GOP Doctors Caucus, U.S. Congress
True health care reform can only begin with a complete repeal of Obamacare.
The Doctors Caucus is committed to ensuring that all Americans have access to quality health care. Doctors believe that chronic illness and cost are two main barriers between patients and quality coverage. Consumer-driven health reforms that seek to put the patient and their physicians in control of how care is accessed can greatly increase a patient’s access to quality health care.
http://doctorscaucus.gingrey.house.gov/
21 members of the GOP Doctors Caucus:
http://doctorscaucus.gingrey.house.gov/whoweare/members.htm

What is the disconnect between the activism of physicians who serve in Congress advocating for social, economic and political changes, and physicians in the community who advocate for ameliorating suffering while contributing to human well-being? Didn’t they all enter medical school with the same altruism? Apparently not.
We now have a politically polarized nation. The medical profession has not escaped this dichotomy. In Congress, it is not as balanced as it is throughout the nation. The GOP Doctors Caucus has twenty-one members, whereas there are only two Democratic physicians in Congress and one of those, as a delegate, is not even allowed a vote on the House floor.
When you read the Priorities of the GOP Doctors Caucus, it is loaded with warm, fuzzy, feel-good language. But if you are a student of health policy, you recognize that they support policies that would greatly increase the numbers of uninsured, and would expand a market of “affordable” health plans that really just shift costs to users, making health care access unaffordable for far too many. That might meet the social, economic and political goals of the GOP Doctors Caucus, but at the cost of exacerbating suffering and further impairing human well-being.
We wish that the partisan divide wasn’t a chasm, but it won’t go away. Voters do bear some responsibility for having selected these physicians to be their senators and representatives in Congress, but it is difficult to blame them when the GOP Doctors Caucus stated mission is “Utilizing medical expertise to develop patient-centered health care reforms focused on quality, access, affordability, portability, and choice.” That sounds pretty good. How could the voters be expected to understand the nefarious policy positions behind that statement?
For health care, many would agree that the filter should be at the medical school admissions committee. Medical schools should select students for whom ameliorating suffering and contributing to human well-being is a part of their soul. The problem is that it may be difficult to find enough admissions committee members who can pierce the obfuscating feel-good language used by too many of the applicants – the type of language that is so effectively used by the GOP Doctors Caucus.
(I apologize to Republican single payer supporters who might object to what seems to be a partisan message. In my defense, the message is about physician politicians and health care justice. It is the Republican physicians in Congress who have made it partisan.)

Physicians for a National Health Program (PNHP)
Press Release, October 12, 2012

A leading authority on behavioral economics has teamed up with two health policy experts in an article at the Health Affairs blog to argue that pay-for-performance (P4P) schemes in medicine may do more harm than good by “crowding out” altruism and other intrinsic motivations to do a good job.

Such P4P schemes, which are being quickly adopted by Medicare and many private insurers under the new federal health law, typically involve giving bonuses to doctors and hospitals for hitting specific, numerical targets in such matters as prescribing certain drugs or ordering screening tests.

However, despite the widespread rush to embrace P4P, a growing body of research has found no evidence that these schemes actually benefit patients, write professor Dan Ariely and physicians Dr. Steffie Woolhandler and Dr. David Himmelstein. Their article was posted to the blog late Thursday afternoon.

Moreover, it’s likely the introduction of such schemes into the cognitively complex work of medicine will backfire, they say.

“Traditionally, economists have viewed extrinsic (i.e. monetary) reward as either the only motivator or as simply additive to intrinsic motivators such as purpose, altruism, mastery, or autonomy,” the authors write.

“According to this view, higher pay induces better performance. But this simple model of reward-induced performance ignores the complexity of human drive, particularly the role of intrinsic motivation – the desire to perform an activity for its own inherent rewards.

“Offering your dinner-party host a $10 reward for cooking a wonderful meal isn’t likely to motivate future invitations.”

The authors cite multiple research studies – involving blood donors in the United States, volunteer workers in Switzerland, and Israelis with children in day care, to name just a few – that show how introducing financial incentives into the picture led to diminished motivation to do the right thing.

They also cite a meta-analysis summarizing 128 studies that show such findings are representative of a consistent body of research.

In addition, the authors warn that “crowd-out” of doctors’ intrinsic motivation may be particularly severe when contracts are more detailed and controlling.  P4P incentives may also lead providers to game the system by checking boxes or exaggerating diagnoses when they know that doing so will garner bonuses.

Pay-for-performance programs also increase administrative costs, they say, citing the extensive economics literature on the downsides of overly detailed contracts.

The authors are recognized experts in their respective fields. Dan Ariely is the James B. Duke Professor of Psychology and Behavioral Economics at Duke University. He is the author of numerous research studies and three bestselling books on behavioral economics, including “The (Honest) Truth about Dishonesty.”

Dr. Steffie Woolhandler and Dr. David Himmelstein are physicians and professors at the City University of New York’s School of Public Health at Hunter College and visiting professors of medicine at Harvard Medical School. They have published many articles in leading medical journals on health insurance and mortality, medical bankruptcy and administrative costs in health care, among other subjects. They are also co-founders of Physicians for a National Health Program, a single-payer advocacy group. PNHP provided no financial or other support for their research.

https://pnhp.org/news/2012/october/financial-incentives-may-sap-motivation-undermine-quality-health-affairs-article

And excerpts from the cited article…

Will Pay For Performance Backfire? Insights From Behavioral Economics

By Steffie Woolhandler, Dan Ariely and David Himmelstein
Health Affairs Blog, October 11, 2012

Paying for performance (P4P) has strong intuitive appeal.  Common sense and rigorous studies tell us that paying more for, say, angioplasties or immunizations yields more of them.  So paying doctors and hospitals for better care, not just more of it, seems like a no-brainer.  Yet while Medicare and many private insurers are charging ahead with pay-for-performance (P4P), researchers have been unable to show that it benefits patients.

Findings from the new field of behavioral economics may explain these negative results.  They challenge the traditional economic view that monetary reward is either the only motivator or is simply additive to intrinsic motivators such as purpose or altruism.  Studies have shown that monetary rewards can undermine motivation and worsen performance on cognitively complex and intrinsically rewarding work, suggesting that P4P may backfire.

The Science Of Performance And Reward

The quality improvement literature has pinpointed many causes of quality breeches in medical care: fatigue; poorly designed workflow and care systems; undue commercial influence; knowledge gaps; memory lapses; reliance on inappropriate heuristics; poor interpersonal skills and insufficient teamwork, to name just a few.  But “not trying” is rarely cited.  Yet P4P implicitly blames lack of motivation for poor quality care.

But even when motivation is the problem, money isn’t always the solution.  Findings from the new field of behavioral economics indicate that performance bonuses often backfire, particularly for cognitively challenging work.

Traditionally, economists have viewed extrinsic (i.e. monetary) reward as either the only motivator, or as simply additive to intrinsic motivators such as purpose, altruism, mastery, or autonomy.  According to this view, higher pay induces better performance. (Figures appear at the end of this post.)

But this simple model of reward-induced performance ignores the complexity of human drive, particularly the role of intrinsic motivation — the desire to perform an activity for its own inherent rewards.

Conclusions

None can doubt health care’s grave quality deficits and cost excesses.  As remedy, P4P suggests manipulating greed, a fuel that’s powered exponential growth in productivity in the overall economy.  But Adam Smith, who first recognized greed’s awesome power, was also a moral philosopher who believed that commodity production required a parallel public service economy driven by social duty.

Sadly, greed has caused many of the worst abuses within the current system.  Injecting different monetary incentives into health care can certainly change it, but not necessarily in the ways that policy makers would plan, much less hope for.

http://healthaffairs.org/blog/2012/10/11/will-pay-for-performance-backfire-insights-from-behavioral-economics/

Comment:

By Don McCanne, MD

Many of us cringe when we see various pay-for-performance (P4P) schemes. Why should that be? After all, providing monetary rewards for improving quality and possibly reducing costs intuitively might seem like a good thing. Dan Ariely, an expert on behavioral economics, along with Steffie Woolhandler and David Himmelstein, provide us with insight. Most of us really did enter the health professions to serve patients, not to sell a commodity.

Financial incentives may sap motivation, undermine quality: Health Affairs article

Physicians for a National Health Program (PNHP)
Press Release, October 12, 2012
A leading authority on behavioral economics has teamed up with two health policy experts in an article at the Health Affairs blog to argue that pay-for-performance (P4P) schemes in medicine may do more harm than good by “crowding out” altruism and other intrinsic motivations to do a good job.
Such P4P schemes, which are being quickly adopted by Medicare and many private insurers under the new federal health law, typically involve giving bonuses to doctors and hospitals for hitting specific, numerical targets in such matters as prescribing certain drugs or ordering screening tests.
However, despite the widespread rush to embrace P4P, a growing body of research has found no evidence that these schemes actually benefit patients, write professor Dan Ariely and physicians Dr. Steffie Woolhandler and Dr. David Himmelstein. Their article was posted to the blog late Thursday afternoon.
Moreover, it’s likely the introduction of such schemes into the cognitively complex work of medicine will backfire, they say.
“Traditionally, economists have viewed extrinsic (i.e. monetary) reward as either the only motivator or as simply additive to intrinsic motivators such as purpose, altruism, mastery, or autonomy,” the authors write.
“According to this view, higher pay induces better performance. But this simple model of reward-induced performance ignores the complexity of human drive, particularly the role of intrinsic motivation – the desire to perform an activity for its own inherent rewards.
“Offering your dinner-party host a $10 reward for cooking a wonderful meal isn’t likely to motivate future invitations.”
The authors cite multiple research studies – involving blood donors in the United States, volunteer workers in Switzerland, and Israelis with children in day care, to name just a few – that show how introducing financial incentives into the picture led to diminished motivation to do the right thing.
They also cite a meta-analysis summarizing 128 studies that show such findings are representative of a consistent body of research.
In addition, the authors warn that “crowd-out” of doctors’ intrinsic motivation may be particularly severe when contracts are more detailed and controlling.  P4P incentives may also lead providers to game the system by checking boxes or exaggerating diagnoses when they know that doing so will garner bonuses.
Pay-for-performance programs also increase administrative costs, they say, citing the extensive economics literature on the downsides of overly detailed contracts.
The authors are recognized experts in their respective fields. Dan Ariely is the James B. Duke Professor of Psychology and Behavioral Economics at Duke University. He is the author of numerous research studies and three bestselling books on behavioral economics, including “The (Honest) Truth about Dishonesty.”
Dr. Steffie Woolhandler and Dr. David Himmelstein are physicians and professors at the City University of New York’s School of Public Health at Hunter College and visiting professors of medicine at Harvard Medical School. They have published many articles in leading medical journals on health insurance and mortality, medical bankruptcy and administrative costs in health care, among other subjects. They are also co-founders of Physicians for a National Health Program, a single-payer advocacy group. PNHP provided no financial or other support for their research.
https://pnhp.org/news/2012/october/financial-incentives-may-sap-motiv…
And excerpts from the cited article…

Will Pay For Performance Backfire? Insights From Behavioral Economics

By Steffie Woolhandler, Dan Ariely and David Himmelstein
Health Affairs Blog, October 11, 2012
Paying for performance (P4P) has strong intuitive appeal.  Common sense and rigorous studies tell us that paying more for, say, angioplasties or immunizations yields more of them.  So paying doctors and hospitals for better care, not just more of it, seems like a no-brainer.  Yet while Medicare and many private insurers are charging ahead with pay-for-performance (P4P), researchers have been unable to show that it benefits patients.
Findings from the new field of behavioral economics may explain these negative results.  They challenge the traditional economic view that monetary reward is either the only motivator or is simply additive to intrinsic motivators such as purpose or altruism.  Studies have shown that monetary rewards can undermine motivation and worsen performance on cognitively complex and intrinsically rewarding work, suggesting that P4P may backfire.
The Science Of Performance And Reward
The quality improvement literature has pinpointed many causes of quality breeches in medical care: fatigue; poorly designed workflow and care systems; undue commercial influence; knowledge gaps; memory lapses; reliance on inappropriate heuristics; poor interpersonal skills and insufficient teamwork, to name just a few.  But “not trying” is rarely cited.  Yet P4P implicitly blames lack of motivation for poor quality care.
But even when motivation is the problem, money isn’t always the solution.  Findings from the new field of behavioral economics indicate that performance bonuses often backfire, particularly for cognitively challenging work.
Traditionally, economists have viewed extrinsic (i.e. monetary) reward as either the only motivator, or as simply additive to intrinsic motivators such as purpose, altruism, mastery, or autonomy.  According to this view, higher pay induces better performance. (Figures appear at the end of this post.)
But this simple model of reward-induced performance ignores the complexity of human drive, particularly the role of intrinsic motivation — the desire to perform an activity for its own inherent rewards.
Conclusions
None can doubt health care’s grave quality deficits and cost excesses.  As remedy, P4P suggests manipulating greed, a fuel that’s powered exponential growth in productivity in the overall economy.  But Adam Smith, who first recognized greed’s awesome power, was also a moral philosopher who believed that commodity production required a parallel public service economy driven by social duty.
Sadly, greed has caused many of the worst abuses within the current system.  Injecting different monetary incentives into health care can certainly change it, but not necessarily in the ways that policy makers would plan, much less hope for.
http://healthaffairs.org/blog/2012/10/11/will-pay-for-performance-backfi…

Many of us cringe when we see various pay-for-performance (P4P) schemes. Why should that be? After all, providing monetary rewards for improving quality and possibly reducing costs intuitively might seem like a good thing. Dan Ariely, an expert on behavioral economics, along with Steffie Woolhandler and David Himmelstein, provide us with insight. Most of us really did enter the health professions to serve patients, not to sell a commodity.