Pay – for – Performance (P4P)

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Pay for Performance & Health Care Disparities TEAMWORK IS KEY…!

Pay for performance  has been embraced by policy makers as a mechanism to improve healthcare quality.  It has been suggested for the past decade that the current system of reimbursement in the U.S. rewards bad care. One potential solution to improving care is to pay providers for delivering good care.  All of the studies that indicate this is effective have been carried out in large centers  or practices with over 100 practitioners.  Most physicians that serve vulnerable populations and minorities do not practice medicine this way. Physicians in these settings will likely be penalized under such programs.  Can a physician working in a disadvantaged area be expected to have patient outcomes that are the same as the physicians on the other side of town who serve the middle class insured? It is well documented that persons of low socioeconomic status have less access to healthcare and experience worse outcomes. Other factors such as health beliefs and culture also impact an individual’s health. A physician providing care to the poor or minorities faces obstacles in treatment that the physician who serves the educated, middle class population will not encounter. Outcomes cannot be expected to be similar. A P4P scheme that utilizes universal criteria will penalize a physician for poor patient outcomes and contribute to many physicians being unable to serve the poor due to the economic consequences. So, a payment structure designed to motivate physicians to improve quality has the significant potential to adversely impact overall healthcare quality by increasing disparities. This does not have to be the history of P4P. A carefully constructed P4P payment scheme, that takes communities, cultures and varying practices into account, does not have to result in economic losses for physicians who serve the poor. In fact, there is evidence that when done correctly, P4P may help to eliminate disparities. Development of such schemes require collaboration between providers and payors and this may be the biggest obstacle of all.

Incorporating Disparity Reduction into Pay-for-Performance
National Quality Forum
AAFP
Pay for Performance and Its Potential Impact on American Healthcare

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5 Responses to “Pay – for – Performance (P4P)”

  1. waleedzafar Says:

    This entry brings up an important point which is how to control for the confounding factors that may explain differeces in disease outcome other than the treating physician’s performance. Thus two physicians may peroform identically but see greater compliance in a middle-class highly educated patient while not see comparable results in a working-class patient who dropped out of high school.

    A second issue is that not all diseases have easily measured outcomes. For instance it might be relatively easy to measure HbA1c in case of Diabetes mellitus or the resting blood pressure in case of hypertension or number of acute attacks in case of asthma but to extend this idea to the entire gamut of medical practice may have unintended and harmful consequences. It might also motivate physicians to achieve short term gains at the expense of long term benefits (rather like the standardized testing and No Child Left Behind laws have done in education).

  2. davidhorrocks Says:

    In my experience, physicians like quantifiable data. Want a doctor to change practices? Show him or her how the data supports the new approach.

    So I find it ironic that a field which is generally quite evidence based, is so resistant to being measured itself. Typically, the objection raised is the difficulty of accurately measuring performance. A common assertion is that the best doctors treat the sickest patients, who are prone to poor outcomes.

    But I would argue that these objections are distractions to the core issue that doctors (as is true for other professionals) don’t like being measured. Even those measurements which can be made accurately are rejected, and this is a shame. The general public has limited ability to judge the quality of their physician, and we owe it to them to provide better tools for evaluation. Measures would tend to promote accountability and performance improvement, and allow in time for the best doctors to be rewarded. The process of data normalization will gradually make physician measures more accurate and meaningful, but we will never get anywhere until we get past the objections and begin to do it.

  3. dauerbach100 Says:

    For the life of me, I cannot even conceive of a system that could accurately and fairly measure treatment outcomes and allow the the distinction between “good” and “bad” doctors. Does practicing defensive medicine or the free prescribing of unneeded antibiotics make one good or bad? How could there ever be a comparison between diabetes control in patients with only that complaint vs. the diabetic with multi-system disease. I can think of no change in the current health care system that would damage physician and patient alike as much as this suggestion.

  4. davidhorrocks Says:

    While there is an intensity to some objections, I believe calm arguments can influence policy towards measurement. We all know that some physicians do practice defensive medicine and others the free prescribing of antibiotics. This demonstrates variability and actually underscores the need for measurement. Not every physician is equal, and good public policy would promote mechanisms to evaluate performance.

    To argue my case with policy makers and the public, I would first point to anecdotes of particular physicians who have run amok due to limited oversight and measurement. For instance, this year in Baltimore a physician was alleged to have implanted upwards of 500 unnecessary stents.

    Patients learn they might have unneeded stents: http://articles.baltimoresun.com/2010-01-15/health/bal-md.cardiac15jan15_1_stents-heart-patients-cardiac-catheterization

    I would pair this with other examples of physicians with economic incentive to recommend procedures, asking the public if they trust anyone to make good judgments when financial gain is to be had.

    Lastly, in anticipation of strong resistance from some stakeholders, I would point to the example of the DC School District, which has bucked the strong resistance of teachers to measurement and is now rewarding top performers and dismissing those at the bottom. The teacher arguments against performance measurement had been similar, and the potential benefits are somewhat analogous.

    D.C. Schools Chief Scores Gains, Ruffles Feathers: http://online.wsj.com/article/SB122636956488016241.html

  5. public good Says:

    This blog, and the comments posted so far, illustrate an important point in the “P4P” movement: people are talking about different things. Unfortunately, the underlying intent, to incentivize good practice, is often lost in the shuffle.

    First, I would strongly disagree with comment that the barrier to P4P is physicians’ resistance to being measured. Data on medical registries, the most dynamic form of practice measurement, has been overwhelmingly positive on the physician side. Registries allow physicians to take an overview, of, say, what proportion of their diabetic patients have reached a target A1C of 6.5. Registries also allow physicians to modify their practice in real time, identifying what portion of those diabetic patients, for example, have not registered a urine microalbumin test this year. Nationwide, physician practices have been adopting EMRs, in part, to supply this type of registry functionality. Registries, however, do not typically punish the physician; they offer pointed, useful data.

    P4P structures, on the other hand, are often misused. My hospital adopted a P4P scheme three years ago to “reward” physicians for “best practices” in hospital care. The reality is that they measure length of stay against a standard of RVUs established by insurance companies, and they give physicians small bonuses for falling within or below that length of stay. The result is that physicians are incentivized to discharge patients from the hospital as quickly as possible, regardless of frailty, social circumstance or possible risk. Because that helps the hospital’s bottom line. Not a great motivational structure. On top of that, the standards for length of stay are absurdly brief in most cases.

    So, I agree with the authors of this blog that an accounting of terms is needed, and that P4P systems need to be more flexible in accounting for variance in many factors, factors that include patient responsibility – not just physician behavior.

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