Faut-il financer la qualité des soins et adopter le « pay for performance » (P4P) des anglo-saxons ?

Payment for performance (P4P) was initiated in 2004 in England. It has since developed in many OECD countries. In France, it was included in 2008 in income on public health objective (ROSP) for general practitioners. It has been applied to hospitals in 2017. P4P raises three types of questioning: philosophical questioning opposing the morality of duty to utilitarian ethics that gives priority to the results, psychological questioning on the respective place of the intrinsic motivation, and the extrinsic factors of motivation, and among them financial remuneration, finally questioning about the evaluation of the results. After 15 years, it is clear that the P4P results are disappointing: benefits are modest, inconstant, transient, concerning more procedural indicators than clinical outcome indicators. The disappointment is particularly strong given the amount of money involved and the possible adverse effects: less patients selection than the deterioration of unpaid quality indicators, and the penalization of hospitals taking care of the poorest and the most serious patients. Finally, P4P did not lead to a decrease in mortality and was not accompanied by an improvement in doctor/patient relationship. Alternative policy is based on training, teamwork, coordination of professionals, and multiple assessments including that of patients, with a feedback to the professionals before public reporting.