Introduction
Health care practices largely rely on effective management of patient care. There are various facets of this medical branch that are constantly modified with the upcoming needs and trends. In order to better establish relationship with patients and gain trustworthiness there is a great need of valuable services which ultimately depend on quality.
In the recent years, a novel promising tool in the health care industry known as Pay for Performance, also known as P4P has drawn the attention of many researchers.
P4P is a process of rewarding the health care providers, physicians, hospitals, and medical groups for rendering effective health care services to patients through pre-established targets. It was considered as the basic alteration of fee for service payment. This system of service is also driven by incentive programs with the objective of enhancing the quality.
However, ethical considerations also surround these services and need to be carefully evaluated before implementation.
Main body
Snyder and Neubauer (2007) described that although P4P program has the potential to develop an efficacy in care; it has to abide with the objectives of medical professionalism. This is because in certain instances there may be chances of deselecting patients such as elderly with multiple chronic conditions on the grounds that they are complicated.
This may indicate a total negligence by giving an impression that these services are just for ‘pay’ but not for the patient.
Therefore, P4P may face strong set back on these old age service ethics. These problems are not confined to a particular study. It was reported that P4P studies are still inadequate with average gains in performance and need to consider key issues such as the choice of clinical practice area, the size of financial incentives and
the details of persons receiving them, the selection of quality measures and performance thresholds that determine incentive eligibility and data collection methods (Scott, 2007).
P4P has prompted investments to be made on health information technology (health IT) such as electronic health records (EHRs) and electronic prescription (e-prescribing) systems. But it was found that several issues have been raised as they are costly, incentive usage is misaligned, and difficulty in implementation and possibility of work interruption (Cusack, 2008).The ethical issues arise when the patients’ health data is shared or linked without the knowledge of patient. Trustworthiness would be lost if the patient’s health data gets exposed through human errors or theft. This would finally diminish confidence in patients making them hide necessary information and getting therapeutically compromised.
Therefore, there is a need to better address these ethical implications of (EHR) by health personnel, leaders, and policy makers (Layman et al., 2008).
Next P4P has also served its utility in the emergency medicine at the group level or indirectly through hospital reward programs. (Sikka, 2007).But it was reported that emergency clinicians should recognize patients’ sovereignty and values, and incorporate relevant bioethical principles mostly those included in professional oaths and codes. (Iserson, 2006).
Therefore, it is reasonable to infer that while implementing P4P, clinicians should care human perceptions regarding treatment but not solely rely on value based measures.
P4P services need to depend largely on hospital staff especially nurses. Previous workers reported that comparatively less attention was given to nurses and nursing care. So, in order to understand the impact of the pay-for-performance measures on nursing labor and processes, attention should be given to nursing leadership (Bodrock & Mion, 2008).
However, there may be possibilities of ethical dilemmas that may affect P4P.Donnelly (2000)reported that cultural misunderstandings and language differences could result when the health care providers lack an awareness of the value systems of patients that differ from theirown. Since nurses are considered as valuable health care providers of P4P, they need to avoid all ethical problems likely associated with cross-cultural nursing.
P4P has developed in some countries where it was introduced for family practioners, in a contract form that increases existing income according to performance with respect to quality indicators covering clinical care for 10 chronic diseases, organization of care, and patient experience (Doran et al., 2006). But it was found out that Pay-for-performance incentives with such contracts are not dealing with disparities in the management and control of some diseases like diabetes between ethnic and socioeconomic groups (Millett et al., 2007)
Therefore there is a need of quality improvement initiatives that must incorporate greater emphasis on minority communities to avoid continued disparities in mortality from cardiovascular disease and the other major complications of diabetes (Millett et al., 2007).
It may indicate that P4P interventions might contribute to possible ethical problems if the existing disparities are not resolved. Mehrotra et al. (2007) described that P4P incentives mostly reward higher clinical quality and has better scope.
This was further strengthened by another report of developmental P4P programs that described the importance of both financial and non financial incentives in motivating significant changes in health care delivery, but the return on investment of these initiatives is not known yet (O’Kane, 2007). In contrast, it was believed previously that monetary incentives may possess features that are toxic to systemic improvement and high performance (Binderman, Kilo, & Oldham, 2000).
The main concerns were that it might erode opportunities for true improvement, breed an atmosphere of expectation, decrease innovation, injure intrinsic motivation, and damage teamwork. It was also suggested that monetary incentives should be given to a whole group or team of individuals to inspire teamwork, learning, and for obtaining greater productivity (Binderman, Kilo, & Oldham, 2000).
Here, it may indicate that P4P incentives appear promising in providing efficient health care despite serious drawbacks from the other side.It was of concern that P4P might introduce an unevenness of power that could affect the balance between patients and clinicians. This would predispose clinicians, who work for obtaining positive outcomes, to addictive behavior and might further increase the chances of ethical abuse (Taub,2007).
Keeping in view of real world P4P, several practical issues have been identified with the objective of improving and conducting pay for quality (P4Q) programs in different market environments. These are specific strategies for choosing quality metrics, units of accountability, size of incentive, data and measurement systems, payout formulas, and collaboration among payers (Young and Conard, 2007).
However, P4P may also face tough competition with disease management (DM) which is considered as a system with coordinated health care interventions and communication for populations with conditions in which patient self-care efforts are significant.
Smith (2007) described that in the current practice both DM and P4P were successful in providing efficient health care services to patients in terms of reducing costs and delivering quality. Therefore, health care providers who strongly rely on P4P may also need to adopt DM policies to ensure better managed care. This may be because growing dilemmas on P4P may enable patients choose alternative approaches like DM.
In such circumstances, physicians or other health care providers need to value patients beliefs and perceptions regarding a particular health care service by maintaining better patient relationship and without creating a possible ethical link.
Cutler et al. (2007) described from an evaluation study that a large group of 165 diabetic patients managed in a chronic disease care management (CDCM) program in a medical group operating under a small P4P financial incentive have shown higher rates of low-density lipoprotein cholesterol (LDL-C) lab testing and goal achievement than from patients managed by routine care.
This report may indicate that P4P is successful in offering its valuable services to a large size of subjects compared to conventional practices. It may have better implications if the similar strategy is extended and employed during other disease investigations.
This was further strengthened by another report that highlighted the importance of P4P while reviewing the various treatment interventions available in diabetes care. It has described that is essential for employing P4P initiatives as components like patient self-management education, provider contact, and the use of the American Diabetes Association (ADA) standards of care measures for screening and lab levels, in order to succeed in a diabetes management program (Cornell, 2007).
Therefore the major subcomponents of P4P identified here might ensure quality in rendering effective health care services to patients. This may be because education would
help in avoiding the likely misconclusions regarding a particular health care service and might enable positive dealings with health care providers, without landing in ethical dilemmas. The use of ADA standards would strengthen the confidence and fidelity in patients and enable them to stay accustomed to the current health care practices in use.
For example, it was found that diabetic patients involved with self-management education programs demonstrated reductions in glycosylated hemoglobin levels indicating that such programs would help patients manage symptoms and contain utilization of health care resources for several chronic conditions (Warsi, 2004).This was further supported by another research that described that patient (consumer) education and self-management programs and practices might help people with chronic disease live better by improving health outcomes and psycho-emotional and psychosocial measures (Koehn & Esdaile , 2008).Since provider contact has also been regarded as a component of P4P, it is reasonable to introduce communication.
It was described that there is need of researching patient-doctor communication and identifying the essential teaching strategies for measuring the clinical skill.Hence, developmemts in the provider-patient communication can have beneficial effects on health outcomes (Teutsch, 2003).
Communication would narrow the gap between the health care policy providers and patients thereby bringing the effective quality services to the patient door step.In order to deliver quality health care through P4P, there is a need to educate the patient such that it would influence the collection of vital information enabling him to act as an informed participant in his or her care. The patient should understand all sorts of educational interventions and sensitive issues like culture and on the whole he should receive information that would facilitate his successful participation in treatment (Musto, 2003).
Therefore, these reports may obviously indicate that P4P interventions are in constant need of components which should be improved by all means. This is only possible by carefully reviewing the available data and bringing modifications if required. Hence, health care providers must realize the importance of these components and strive for their validation through implementation.
Further, as P4P interventions still require large studies for their quality delivery, there may a need to shed some light on subject selection. Patients may be generally selected by conducting surveys and retrieving the information from the National databases.
In an earlier study, to evaluate the relationship between maternal Selective serotonin-reuptake inhibitors (SSRI) use in early pregnancy and the occurrence of selected birth defects, researchers have used data from the National Birth Defects Prevention Study (NBDPS). Telephonic interviews were conducted to select the patients based on risk eligibility criteria set by clinical professionals (Sura Alwan et al., 2007).
In a random study on Pay-for-performance programs, researchers have extracted data from computing systems for 8105 family practices, data from the U.K. Census, and data on characteristics of individual family practices. They have employed clinical quality indicators to make them eligible for the study (Doran, 2007).It is reasonable to assume that the policies of P4P hold good for all kinds of clinical based settings and investigations due to its close attachment with patient care. Therefore, it can be inferred that the data collection process mentioned previously is in agreement with the guidelines set by American Medical Association (AMA) regarding pay – for- performance programs.
According to AMA guidelines, the intervention programs should use accurate administrative data and data abstracted from medical records. It is essential that the information obtained from the data would be reviewed and analysed physicians before using any rating system to determine physician payment or for public rating, which is also as per the AMA guidelines.
Therefore it may indicate that selection of subjects for intervention programs like P4P must get aligned with the stringent data collection process and analysis set by an authorized body.
Finally, it is essential to compare the P4P programs with non health industries which in the present case in Marketing.
In the recent years, internet advertising has contributed lot to the online marketing. It was reported that a wide range of online advertising companies are diverting their attention towards pay for performance marketing from their earlier method of disappointing cost-per-click module.
Here, the methodology involved was that advertisers would begin pay only for the clicks that led to consumer activity such as requesting more information, becoming a registered member of the site, and finalizing a purchase. In contrast, P4P programs in health care depend on quality that is possible only through the effective service deliveries to the patients and outcomes.
P4P in marketing initially requires some prior investment where as that in health care might generally require a later investment in the form of fees.P4P programs in health care in health care have to abide with the rules and regulations of professional organizations.
Where as those in marketing need not to depend so. The quality of Health care P4P’s mostly depends on physician –patient relationship where as that in marketing depends on investor – advertiser relationship. Ethical dilemmas that frequently interfere with the health care P4P’s and are inevitable and need to be carefully addressed. Whereas the chances of ethical interference in marketing although appear hidden may interfere possibly and could not be tackled easily as they escape the regulations across national boundaries.
This is because the efficacy or the pitfalls of health care P4P’s may be easily checked by an expert committee where as marketing PFP’s evade this process by seeking the aid of web technologies thus increasing the ethical complexity.
Trustworthiness would be generated from the patients in cases of effective health care P4P management. In contrast, despite increasing efforts efficient marketing P4P, trustworthiness would be lost because of increasing online advertising frauds and E-business email scams. Health care P4P ethics are more confined to patients where as marketing P4P ethics are unconfined and unbound.
In view of the above information, it is apparent that the P4P programs are not naïve and have been modified over the years with the changing opinions of people and providers.
It gives an impression that it is more attached to medical professionalism than other established fields. Various authors have contributed to bring the P4P to the forefront of common people and medical society.
Conclusion
Since the commencement of P4P a lot of ethical dilemmas and human errors have squeezed the essence of this emerging health care service tool. Financial and monetary incentives have been recognized as the promising channels to promote the growth of P4P. But concerns arise on ethical grounds fearing that it might fail to value human beliefs.
Information technology has shaped P4P through electronic health records (EHRs) and electronic prescription (e-prescribing) systems. But ethical concerns again interfere and indicate that the sensitive and valuable information of patient might get open access if due to technical snags or human errors. However, in depth studies have identified major components of P4P such as patient management education system and communication that may have better implications for revolutionizing the P4P practice. In addition, the guidelines set by AMA appear to protect the privacy of P4P making it an indispensable tool in health care administration. On the whole, both health and non health P4P policies need to be thoroughly regulated to safeguard and respect the ethical considerations.
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