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Financial incentives and mortality: taking pay for performance a step too far
  1. Kiran Gupta1,
  2. Robert M Wachter1,
  3. Allen Kachalia2
  1. 1Department of Medicine, University of California San Francisco, San Francisco, California, USA
  2. 2Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
  1. Correspondence to Dr Kiran Gupta, Department of Medicine, University of California San Francisco, San Francisco, CA 94143, USA; kiran.gupta{at}

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In the USA, hospitals are increasingly evaluated and paid, based on a burgeoning list of publicly reported quality and safety metrics. Performance measurement is undoubtedly essential for improving healthcare quality, but developing the ‘right’ metrics has remained a formidable challenge1 and has resulted in significant discourse over the validity, authenticity and utility of several publicly reported measures.2–4 Yet, despite the debate, the amount of financial incentives tied to quality metrics continues to grow.

As stakes for physicians and hospitals in the USA continue to rise, several of the measures used in performance programmes have come under greater scrutiny. For instance, the use of the Patient Safety Indicator-90 (PSI-90) measure—a metric comprised of eight distinct PSI measures weighted to varying degrees—in two major pay-for-performance initiatives has been questioned for its validity.2 Another measure increasingly tied to financial incentives in the USA is hospital mortality. We believe its use, while well intentioned and with some value, is too problematic to merit inclusion in pay-for-performance programmes.

In 2008, the Center for Medicare and Medicaid Services (CMS, a US federal agency responsible for the administration of Medicare and Medicaid insurance products that provide health coverage for the elderly and the poor, respectively) began publicly reporting 30-day risk-adjusted hospital mortality rates (death within 30 days of admission adjusted for selected comorbidities) for Medicare patients admitted with one of three conditions: acute myocardial infarction, heart failure and pneumonia. The decision to use risk-adjusted hospital mortality rates in quality measurement and public reporting to drive improvement in care is understandable. Mortality is perhaps the ultimate outcome in healthcare, one that both providers and patients care deeply about.

Indeed, the use of risk-adjusted mortality as a publicly reported measure appears now to be a fairly well-established practice. For example, public reporting of risk-adjusted mortality rates for …

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  • Contributors All authors made substantial contributions to this manuscript including drafting the manuscript and revising it critically. All authors approved the manuscript version being submitted for publication.

  • Competing interests Dr. Wachter reports that he is a member of the Lucian Leape Institute of the National Patient Safety Foundation (for which he receives no compensation); has previously served as a member of the ABIM Foundation board (for which he received a stipend); has a contract to UCSF from the Agency for Healthcare Research and Quality to edit a patient-safety website; receives compensation from John Wiley and Sons for writing a blog; receives royalties from Lippincott Williams & Wilkins and McGraw-Hill for writing/editing several books; received a stipend and stock/options for having previously served on the Board of Directors of IPC Healthcare; serves on the scientific advisory boards for, PatientSafe Solutions, QPID Health, Twine, and EarlySense (for which he receives stock options); and holds the Benioff endowed chair in hospital medicine from Marc and Lynne Benioff.

  • Provenance and peer review Not commissioned; internally peer reviewed.