Kevin, M.D. - Medical Weblog

Unfortunately, this P4P scheme wont stand. What will happen is that the govt will start cutting the P4P bonuses until its a budget neutral item.

Right now, P4P probably pays each doc like $15 or $20 to talk to their patients about smoking cessation. Watch that bonus start plummeting. I bet within 5 years you will see that figure drop to $2 or less.
 

So the argument is that it is a bad idea to pay doctors more because you may have to reduce it in the future?

If taken on a whole, the idea of P4P is to cut down on the costs that occur with poor quality. The whole motivation for P4P is not to change payments, it is to encourage quality and ultimately reduce costs. Good cholesterol control should reduce the need for future cardiac procedures or admissions for CAD or CVA's.

Anyway, since there is no proof that cardiac stenting actually saves lives, why don't they just shift all the money they are throwing at cardiologists for doing that and give it to primary care doctors for preventing heart disease?
 

qIf taken on a whole, the idea of P4P is to cut down on the costs that occur with poor quality. The whole motivation for P4P is not to change payments, it is to encourage quality and ultimately reduce costs.
As far as reducing costs is concerned: unless you can eliminate death, you are not preventing the desease, you are only postponing it or replacing it with another desease later on. So while all of us whose life is prolonged agree that it is a good thing, the payer who couldn't care less about our lives might think otherwise. From the payer's point of view my second cousin's husband who died of an immediately fatal heart attack at the age of 52 saved money. If he had bothered to go to a doctor and control his blood pressure and probably also cholesterol he might've lived longer, but he'd used up way more money.

A lot of people often confuse cost-effectiveness with cost-savings. These are not the same. Cost-effectiveness usually means that the amount spent on prolonging one person's life by one year is under $50,000. This is really different from cost-savings. So you can find a million of articles that show how this or that is cost-effective, but you'll be hard pressed to find anything proving total cost savings. Many try, but they often fail to take everything into account.

While many preventive measures are cost-effective, very few of them are cost-saving. Vaccinations for example is both cost-effective and cost-saving, pap smears may be too. The case is much tougher to make for many other deseases.
 

One thing that is often missed when talking about P4P is the patients' contributiuon to P4P. Something like talking about smoking cessation is one thing, but it is a misleading example. How about prescribing statins for elevated cholesterol? If P4P metrics are determined by insurance records (i.e. bills) as they are likely to be in the US, the physician is likely to be penalized when patients opt not to have the prescription filled. The percentage of patients who should be on statins but who are not is reduced and the physician is penalized (or not bonused) etc.

The likely result of this is that the physician will be very choosy about his patients. If you are sick and have a likely poor outcome, have a history of "non-compliance" or poor self care, etc., expect to be turned away as a patient, because your mere presence on a physician's panel will reduce his/her revenue.
 

Diabetics account for 10-15% of the population, while accounting for at least 30% of the cost of healthcare in America. Treating diabetes right is cheaper in the long run than doing so poorly. With the current state of medical technology, we keep sick people alive for a long time, so it is more expensive for a 40-year old to have CAD than an 80-year old (in the big picture of cost). We use all sorts of medications and procedures to keep that 40-year old alive for 15-20 years, while the 80-year old overall has a shorter life-expectancy (obviously).

Again, my main point is that the government and insurers are banking on the fact that it will save money to prevent disease. Why else would the push for P4P? They often are increasing utilization in the short run (more Mammograms, A1c's, Lipids drawn, eye exams, etc.). They are trying to save money and see this as the means to do that. Will they be right? You think not, I think so. Time will tell.

Regarding selection of patients, it may happen, but we are soon getting our $5000/physician bonus for quality and we never selected. The quality of care is poor enough that simply applying good care will cause numbers to exceed the threshold for most P4P bonuses. If doctors use the dismissal of noncompliant patients instead of just applying good care, then shame on them. I have never dismissed a patient due to noncompliance and my quality numbers consistently are twice the national norm. If physicians are that much opposed to using evidence-based standards, then no solution will succeed.

By the way, why always anonymous? What is there to hide?
 

Regarding selection of patients, it may happen, but we are soon getting our $5000/physician bonus for quality and we never selected.

1. Was the extra effort in terms of manpower, paperwork, etc., worth more or less than $5000?

2. Could the time have been spent seeing higher volume and generating more revenue than $5000?

(These are just pragmatic questions about this issue - I am not implying that it is the only consideration).

3. You have "Never" opted out of this or that insurance plan or group plan or other structured payment system because of the fee schedule? Do you take ALL plans or have you opted not to accept some because the fee schedule is unacceptable? Or the burden is out of proportion to the fee schedule or expected revenues? Hard to believe.

Physicians choose patients individually and in groups for all sorts of reasons.

I happen to agree that quality improvements can ultimately reduce costs, and better care is a good idea anyway. But we are naive if we believe that a third party payor wants to encourage costly activity that will produce cost savings in 2-3 years. In all likelihood, the subscriber would have another plan by then (in non-government plans). It is also naive to think that altruistic doctors will continue to see all comers regardless of the impact on their revenue.

If doctors use the dismissal of noncompliant patients instead of just applying good care, then shame on them.

I personally do not think I would dismiss a patient for non-compliance, but it is naive to think that it wouldn't happen on a large scale.

How does one "apply good care" for diabetes or high cholesterol? I can recommend this or that medication, recommend ophtho exams, examine their feet 4 times yearly, do annual urine screening for albuminuria. I can counsel them on good foot care, the importance of medication, diet. But if the other 361 days of the year the patient eats twinkies, doesn't check their blood sugar, skips medications or just doesn't take them, was good care applied? How was the good care that I provided then measured?

I think there is an inherent problem in the metrics used for P4P, because they are not under the physicians control. We would not accept a drug trial that did not apply interntion-to-treat principles, so why are we not insisting that the same principle apply to quality measures. Instread of measuring how often a patient with LDL=160 refills their Zocor, find a way to measure whether or not I actually recommended it. It should count that I recommended it even if the patient says "no way." I get the performance reports constantly from the plans in which I participate. All of the data are based on billing records. At least I know which patients aren't filling their medications. As long as performance measures are based on billing records, physicians in affluent areas with a highly educated population are going to do better on quality measures regardless of what they do.
 

About cost. While I agree that good quality care (provided you know how to measure good quality care) is great, and some quality measures may lead to cost-savings, it is not at all obvious that all metrics currently used will lead to cost savings. And if anybody believes in government's ability to make sound fiscal decisions, how would you like to buy a bridge?

Just because controlling diabetes is cost-saving, doesn't mean that every measure is cost-saving, especially if the measures include primary prevention when you need to treat quite a few people for quite a few years to prolong one life. Nor does it mean that all measures combined are cost saving.

Take mammograms for example. It seems intuitively that they should save money - until you consider the number of women you need to screen to prolong one life, number of false positives, biopsies and the increased number of women to treat. Look for example, at these pretty optimistic numbers and notice the magnitude of the increase in incidence, a certain part of it is due to overdiagnosis. Keep in mind that the article uses biennial screens, the rate of false positives after annual screens as in the US will be significantly higher. The actual cost of screening in this case is several times greater than all the savings one can get from possibly less treatment for a few. You also need to consider, by the way, that in cases when mammograms don't make a difference in final outcome, you have a longer period of treatment. Do the math.

I don't know if cholesterol control is cost-saving, especially when you are talking about primary prevention. When you talk about how a heart attack at 40 is cheaper to treat than a heart attack at 80, you need to consider how many people you need to treat to prolong this one life. Add to it, that every person who takes drugs needs more office visits; maybe blood tests; some people complain of side effects whether or not caused by medication - more office visits. Same about blood pressure control. Obviously, the numbers would look better for people at higher risk, but the guidelines do include primary prevention.

The reason I am so fixated on cost by the way is because when one starts talking how these measures save money, one immediately jumps to labelling healthy people who exercise their right to informed refusal as "irresponsible". And from this, there is only a small step to penalties for those who refuse. I think good quality is adequately informing patients of benefits and risks, not sugar-coating the risks and overestimating the benefits. If the doctor is paid more based on number of patients who comply, he/she has no incentive to adequately inform.
 

It is amazing to me that I am the only blogger who seems to see some sense in P4P.

OK, Rich: But we are naive if we believe that a third party payor wants to encourage costly activity that will produce cost savings in 2-3 years. In all likelihood, the subscriber would have another plan by then (in non-government plans).
So then why are they doing it? Surely they would not institute a plan that would cut into their profits? Do you think they are doing this to ultimately cut doctors' compensation? Why wouldn't they stop paying for unproven procedures instead - such as angioplasty and stenting. These procedures are quite costly (probably more than the cumulative bonuses that the PCP's would get from P4P) and have never been shown to reduce mortality or morbidity.

I too would never want P4P that was controlled by the insurance companies. Their claims data is very poor. This is why Medicare wants physicians on EMR (through the DOQ-IT project) - the data from the physicians themselves is far more accurate. This is how I am getting my first quality check - via reporting from my database.

Yes, we are investing more than the $5000 per physician to get our bonus, but it is gratifying to actually be paid for quality. We have always been penalized for it (by decreasing patient volume). This is the start of a process that will hopefully result in a good ROI. Even if we break even, it will be nice to not have to compromise our business by doing quality medicine.

I did not say we did not opt out of an insurance plan, just that we did not discharge a patient for noncompliance.

My point on the dismissing of patients was this. Most physicians are shocked when they look at their quality numbers. When we first looked at our numbers, they were amazing - low diabetic eye exam rate (national average is around 10-20%), many patients missing A1c for years, etc. We have found it far easier to just improve the process than to weed out bad patients. The P4P measurements will be attainable by system improvement. If physicians resist improving their process, then they will lose out. I have no problem with that.

Diora: Point well made on the Mammograms. Yet the insurance companies pay for a lot of things they lose money on - cholesterol medications, colonoscopies, etc - they are simply the cost of running the business. They also pay for many unproven procedures (bypass grafting is used more often when not indicated scientifically than when indicated). The reason they pay for these is because it is standard of care.

I actually said that a 40-year old with an MI is more expensive than an 80-year old. Sick old people cost less than sick young people because they aren't sick for as long. They die easier, and people are willing to quit sooner. So preserving someone's life until 90, when the "will eventually die from something" does not mean that it is a wash financially.

FYI - Our practice has been nationally recognized for quality and efficiency. We have been a case report before congress in the use of EMR for improved process and quality. I have worked with CMS, HIMSS, ACP, AHQA, and other organizations in these areas. I have spoken around the country on practice redesign and use of information systems to improve the quality of care and the business of medical practices.

Through my involvement with folks fairly high up, I am absolutely convinced that P4P is coming. My question to the physicians is whether we want physicians designing it or if we want insurers and congressional committees doing it. If we resist the whole way, then we will get what they want. If we do it, then we can have some say in what it will look like. I know that if we do nothing to shape it, we will be the most hurt by what it ends up as.
 

Rob,
my main concern with P4P is that doctors are judged for patients' compliance. Also for blindly following guidelines regardless the individual patient's situation.

With the current proposal, if a patient refuses to follow guidelines for whatever reason he is messing up your numbers. Wouldn't you like then to get rid of such a patient? Wouldn't you also have incentive to do what Virginia plan's does and penalize patients for not following guidelines? Also, there are different ways to present the benefit. Using relative risk reduction sounds much higher than using absolute risk reduction, for example, and lifetime risk of getting the desease is always scarier than the actual chance of dying from it in the next 10 years. P4P gives incentives to present the information in a misleading manner.

Also, if a patient comes to you for an unrelated problem, wouldn't you be hard pressed to spend significant part of the office visit making sure the guidelines are followed rather than the problem that actually interests the patient: "doctor, my throat hurts", "ok, let's see when was your last mammogram?".

And I wasn't questioning why insurance companies pay for the procedures - this is clear and they certainly should, only the premise that P4P saves money. It saves in some cases, it doesn't in others. The total isn't as clear. But as soon as it is assumed that the complete package (that includes both cost-saving and not cost-saving measures), the patients who choose to exercise their right to refuse start being labelled "irresponsible". Inevitably, some bureacrats decide it would be great to penalize the patients. Penalties for patients seem almost a logical extension of P4P plans.