Pay-for-Performance and Accountability

TO THE EDITOR:

I became a cynic early on when it came to the “golden rule.” My father's interpretation (“He who hath the gold, rules”) seemed suitable in the world where I grew up. The emergence of pay-for-performance as described by Rowe (1) is the medical version of my dad's golden rule.

Medicare emerged in 1965, and the patient–physician relationship dissolved into the patient–fiduciary (health plan)–physician cooperative. As the cost of care increased (as one would only expect in any first dollar coverage system), the fiduciary, often a for-profit corporation, needed to cut expenses while increasing market share to maintain a …