Healthgrouper Final report: Stop Pay for Performance (Reporting), now!

95.2% (94.7% preliminary results) of the doctors-specialist consider that the Pay for Performance project as implemented is NOT FAIR and is UNJUST in valuing their work;

88.4% (89% preliminary results) of the doctors-specialist consider that the project reflect negatively over the team work at the departments;

71.4% (70.6% preliminary results) of the doctors-specialist confirm that the project stimulates production of unnecessary procedures to patients;

61.4% (57.3% preliminary results) of the doctors-specialist consider that the project has negative effects over the patients;

Skopje - (November 13, 2012) - A conflict associated with the Pay for Performance (P4P) project that persist in continuity over the past few months between the majority of the specialized doctors employed in the public hospitals and the ministry (minister) of health resulted in new call for a general strike, scheduled for November 14, 2012. The both sides show no signs to change its positions, what just shows that the P4P project implemented in the existing form causes huge reactions. What in fact constitutes P4P project and why it created such big frustration among the doctors?

The P4P in Macedonia is based on mandatory reporting of each intervention/procedure individual physicians perform. The model measures individual physicians’ workload, and not the performance of the clinical team or the hospital. Special web based applications was developed and each doctor with its online login information register interventions he/she performs. The system (application) each month generates monthly reports containing review of all services provided by the doctors at the specific provider. Data are analyzed at the level of providers, and also data are available for control at the Ministry of health. The model does not contain any evaluation system, nor does it include quality measures at the present stage of development. In financial terms it considers 100% salary of individual physician as starting point. Monthly variations in the salary of +/-20% per physician are allowed. The doctors’ performance is compared within their own departments, and not against the other doctors working at similar public providers. In order to gain 20% more, the doctors should take 20% of the salary from their colleagues. Thus, if one hospital/department has on average 50 interventions/procedures per month, while other provider has on average 10 interventions/procedure per month, in the end the model may generates lower salary to the doctors working in the institutions that performs more interventions but performed lower than the average that month. In essence, the model measures individual doctor workload as quantity of the interventions delivered over one month. It does not integrate other performance measures such as quality, teamwork, complexity of the interventions, nor does it include any hospital outcome measures. Thus in fact, the project is not Pay for Performance, but Pay for Reporting.

To assess the actual situation Healthgrouper Research Unit conducted a rapid survey among doctors who are direct participants in the project. Four questions were addressed to the doctors, and possibility to leave open ended comments. In addition, the final question was left open for the doctors to state their main concerns. The survey was completed on November 8th 2012, with responses of 301 doctors specialists. All doctors that have started the survey responded and completed all questions. Healthgrouper for the first time registers such responsiveness and mobility of the doctors in Macedonia.


The findings of the survey show that overwhelming majority of the doctors (95.2%) consider that the project is not fair and does not value the work of the doctors in a just way. (Figure 1);

Furthermore, the results showed that the doctors claim project to have direct negative consequences over the team work in their departments, where 88.4% of the surveyed doctors chose options “very negative” and “negative”. (Figure 2);

To health policy makers a serious concern should raise the survey findings that the project stimulate production of unnecessary checkups, and related diagnostic procedures to patients. (Figure 3).

Finally, over 60% of the surveyed doctors thing that the project reflects negatively over the relationship between doctors and patients.(Figure 4).

The main goal of the modern health care systems is integration of the health care. The currently proposed model for Pay for Performance is in direct collision with this principle and instead to integration and collaboration among the doctors, it leads towards disintegration and creation of personal conflicts that may have far reaching negative consequences for the patients. The final results of the Healthgrouper’s survey just confirm the previous findings that the P4P project should not be implemented in existing form.

Conclusions and recommendation

The Pay for Performance project is NOT FAIR and is UNJUST;

The project reflects negatively over the team work in the hospitals;

The project perversely stimulates production of unnecessary diagnostic procedures to patients;

The ministry of health should revoke, adapt, and gradually to implement the project learning from the current mistakes and comments of the doctors.

In order to reflect the magnitude of the problem Healthgrouper publishes 1000 uncensored comments of the surveyed doctors. 

About the survey

The survey was conducted between November 3-8th 2012. In total 304 randomly selected doctors and 9 administrators participated in the survey. This makes around 20% of all doctors who are involved in the project. The questionnaire was emailed only to doctors who directly participate in the project. All doctors who started the survey responded to all questions.

Healthgrouper is an Internet platform for communication between physicinas and it provides integrated information about health providers in South-East Europe to the patients. Healthgrouper conducts health system research in all countries where the project is active, in order to make comparative analyses for the conditions in the health systems in the region and promote the quality of health care. Final results of the surveys are published online and available in local languages and communicated with the media. For more information, please visit