We have “escape” codes to make sure the doctor is not penalized. For example, if there is a risk of embolism or if there is an aneurysm complication during surgery, then the payment reverts to a fee for service. The point is to ensure patient safety and high quality of care, not penalize the doctor for events not in their control.
If the care being sought is highly experimental or risky, we work with physicians to determine if there are centers of excellence that may provide higher quality of care.
Having the actual results align with the intended ones is easier said than done, as anyone who has ever tried to design and administer any kind of measurement-based compensation or bonus plan will tell you.
That part is easy.
The hard part is aligning providers, patients, and the payers, since the patients cannot afford to align the providers with themselves. Enter politics, because you are now distributing limited healthcare resources with demand far greater than supply, meaning you have to either pony up more from the payers and/or ration various quality of healthcare to various populations, per their political power.
Wouldn't doctors be incentivized by this fee structure to walk away from difficult cases, where a treatment is risky but is the last hope for the patient, if they won't be paid for the likely bad outcome?