The Performance-Based Supplementary Payment System

The PBSP system determines the size of the additional payments to physicians due to their performance. In practice, these additional payments are basically dependent on the number of examinations, diagnostic tests, and medical operations performed by physicians. These payments come from the hospital’s revolving fund. Financial performance is highly dependent on the revenue of hospitals, and it can be suggested that if a hospital earns more money by performing value-added medical operations, it can pay employees more supplements from the revolving fund. As a result, hospitals may induce physicians to perform more examination and medical operations in order to increase their revenue.^{Footnote 7,Footnote 8}

The Ministry of Health and some authors^{Footnote 9,Footnote 10,Footnote 11,Footnote 12} accept that, overall, the health system reforms and HTP are fairly successful in Turkey, and they emphasize the high number of patients treated per day in public and university hospitals. However, from the perspective of healthcare professionals, the situation is different, because they focus more on the qualitative side of performance than on numbers.^{Footnote 13}

The findings of some recent studies among healthcare professionals^{Footnote 14,Footnote 15,Footnote 16} stated that PBSP increases the income of physicians but at the same time increases their work load. According to reports from the Turkish Medical Association Medical Ethics Committee and the Turkish Dental Association Dental Ethics Committee,^{Footnote 17,Footnote 18} most of the physicians and dentists thought that PBSP increased the number of unnecessary diagnostic procedures and interventions without indication. More than half of the physicians and dentists declared that PBSP increased malpractice. It has been suggested that PBSP may contribute to overwork and therefore may contribute to malpractice.^{Footnote 19} Due to the effect of the revenue concerns of hospitals and healthcare workers, physicians may spend less time on examinations, give less attention to patients’ complaints, diagnose quickly, and prescribe unnecessary medicines.^{Footnote 20} In addition, there is too little time to adequately diagnose problems or provide lifestyle guidance, because the Ministry of Health scheduling system sets the length of appointments at 15 minutes. Therefore, patients may not be well informed about the benefits and risks associated with the treatment options available to them.^{Footnote 21} Physicians and dentists working in public and university hospitals underline the fact that they lack the required time and resources for improving themselves professionally within the present system. As the PBSP system does not include allowances for teaching or research, those who are interested in these activities felt personally punished.^{Footnote 22,Footnote 23,Footnote 24}

Ethical Issues Arising from the Performance-Based Supplementary Payment System

The Turkish Medical Association Ethics Committee, Turkish Bioethics Association, and American College of Physicians Ethics Committee have raised the following ethical concerns about the PBSP system:^{Footnote 25,Footnote 26,Footnote 27}

• • Deselecting difficult patients: In a system that rewards good performance on specified clinical measures, strong incentives encourage physicians to improve their performance scores by dropping (or refusing to accept) difficult patients whose outcome measures may not meet the quality standard and therefore might worsen the physician’s profile. This behavior may cause discrimination among patients and violates the ethical principle of justice.

• • Misalignment of perceptions between patients and physicians: Patient care depends on trust. Patients must believe that the physician is acting in their interests, not his or her own. If the patient is aware that the system of care creates conflicts of interest, that can undermine trust—even when the physician is acting only in the patient’s interests. The best way to avoid this problem is to measure and report quality in terms of patient-centered objectives such as continuity, communication, and access.

• • Increase in unnecessary care and medical costs: Physicians have an ethical obligation to use resources responsibly and to help ensure equitable access to resources for all patients. Some patients need more resources than others. The PBSP system, which applies the same quality standards to all patients, could encourage unnecessary care.

In medicine, the success of physician participation in quality-improvement programs has been dependent not only on financial incentives but also on the alignment among these incentives, the clinical areas perceived as important, and the professional and ethical values of the physicians.^{Footnote 28,Footnote 29} Physicians may provide good care because that is the right thing to do, because they are being paid to care for patients and want to do their job well. For physicians, professional training, ethics, and norms of patient-centered behavior are important factors that may limit the impact of financial incentives from the PBSP system.^{Footnote 30,Footnote 31}

It is clear that the PBSP system brings about change in both positive and negative directions. The increased income level of physicians and increased access to healthcare are the main positive effects of PBSP. On the other hand, it seems that great incentives combined with a fixed low base salary may cause increased overuse or unnecessary use of health services, increased competition, decreased solidarity, conflict among physicians, inefficient use of resources, a threat to ethical values, and decreased quality of service.