A very real problem with the pay-for-performance movement:
The AAFP’s Kellerman agrees, noting that “cherry picking and lemon dropping” is a real possibility under a badly designed quality incentive program. And even someone as generally optimistic as David Luehr acknowledges that a system of pay-for-performance that goes too far””that imposes unreasonable goals upon doctors so they’re tempted to avoid the very patients who need them most”””could be very detrimental.”
Related posts:
- Non-compliant or illiterate?
- Non-compliance
- "Primary-care practices in the United States now depend on luring physicians away from other countries"
- Personal responsibility: Penalties non-compliant patients
- Doctor apologies: The real reason why insurers don’t want a "sorry"
- Non-compliant patients
- Directing patients to the ER
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{ 16 comments }
Kevin’s modus operandi: Let’s make sure we bash healthcare improvement that might impose obligations and accountability on MD’s.
That’s a ridiculous comment Elliot. There’s no way the ATLA or ABA would jump on board, say physicians, drawing up quality measurements which would determine lawyer’s reimbursement. That is extensively analogous.
There are major issues with how P4P is going to be implemented which raise concerns.
How can you discount that it won’t happen. As busy as I am if P4P goes through for surgical procedures I could easily send all of my diabetic patients away and keep just as busy. They have known higher complication rates so explain why exactly would I risk bringing my stats down. Where are all of these patients going to go? Since statistics is all that is truly cared for in P4P It will happen. Choosing statistics over patient care sounds like a brilliant idea.
In the end it doesn’t hurt me if payors incentivise things that alter behaviors. As long as we all know the rules of the game and everyone agrees not to act shocked at the results then fine. The entrepreneurial spirit is alive and well in America. Treating the only slightly ill is more profitable than treating the really ill; this is why there are so many specialty clinics and surgery centers popping up.
As a surgeon, I already try to cherry-pick my patients. If they have significant comorbidities, are non-compliant, or smell even slightly litiginous, off they go to a tertiary center. I’ll be damned if I will operate on someone that is high risk for complications for which I will get blamed for and possibly sued for. If P4P occurs, I believe all surgeons will cherry-pick even more.
I figured out many years ago that the key to having a bad reputation as a psychiatrist is to take the folks into your practice who predictably never do well. The logical corollary of that, that the key to a good reputation is to cherry pick patients who you know will do well, took me another 20 years to realize and to implement.
This is a sad and fascinating conversation. To think that physicians can improve their reputation by refusing to care for certain people seems desperately ironic. Yet I can see how this may certainly be the grim reality.
Kevin’s modus operandi: Let’s make sure we bash healthcare improvement that might impose obligations and accountability on MD’s.
Agree that it is a ridiculous comment. Did Elliot even bother to read the article? As a patient, I want my doctor to explain to me the risks and benefits of the proposed treatment and then accept my decision based on what I feel is right for me. If a doctor has a stake in my choice, how can I be sure that he/she is honest with me about risks? If there is a threat that a doctor will dump a patient who makes a “wrong” decision, there is no true freedom to make one’s own choices. What does measures that provide incentives to doctors to deny patients their right to informed consent have to do with obligations and accountability? It is not doctors’ obligation to force people to take medication, for example, only to recommend it and to explain risks of not taking it. Or do you propose doctors tie every non-compliant patient up and force it down his throat? Or spend 70% of an already brief visit on convincing a patient to take a drug or a test that has 1/1000 chance of preventing something bad instead of listening to some symptoms that concern this patient?
In the end it doesn’t hurt me if payors incentivise things that alter behaviors.
It has a potential to hurt. Most interventions – be it tests or drugs – have risks. Even life style choices are not always obvious: exercise might prevent a heart attack in one person but cause an injury in another. Even if the number of people who’d benefit is significantly higher than those who are hurt, you never know if the particular person will benefit or will be hurt. In some cases, a lot more people benefit then are hurt, but in some the choice is not as clear. The latter is especially true for primary prevention when the probability of benefit to an individual is so small, that even a tiniest of risk may be important to a person. An individual who has side effects from some medication might decide that 3% chance of avoiding a heart attack (for example) 10 years in the future is not worth sacrificing quality of life now. For another patient a tiniest chance of a rare but scary risk may be more important that a higher chance of something bad happening some years down the line.
The right to refuse treatment for whatever reason is a right. By dumping patients who exercise their right to make decisions about their own bodies, you are hurting them. If all doctors have incentive to dump patients, where will these patients go?
What if what is now P4P requirement turns out to be wrong tomorrow? Is it completely impossible? Can you be sure that what you’d end up pressuring your patients to do today will not be shown harmful tomorrow and will not end up hurting more people that it’ll save?
From my conversations with physicians who participate in some form of p4p, the problems isnt’ with the ideals and metrics. It’s the ROI. The amount of time it takes to collect, analyze this data, and pass on this data to the insurers makes this “not worth it.”
However, despite it’s problems with non-uniform definitions of “performance”, ideally ALL MDs should at a moments notice, know the “health status” of there practice. Trust me, each MD that complains about the effort it requires, they know exactly what their A/R is, their insruance mix, etc. Every practice has been using practice management systems for nearly 10-20 years now.
If we are obligated from a business sense to know, and understand the financial status of our practice (no money, no mission), than as physicians aren’t we collectively obligated to know the health status of our practice.
Instead of trying to figure out how to game a corrupt and inadequate p4p system, focus on just being the best MD we can be, which includes being aware of the exact numbers of compliant and noncompliant patients we have, how many diabetics on ACEI and not on ACEI we have, how many CAD patients are taking their ASA and how many are not, etc.
I ask how can anyone take seriously this issue of noncompliant patients if the doctor himself doesn’t even know how many noncompliant patient he has in the first place?
Come on now, lets be real. The “health status” of my practice? The bottom line is that what matters is the what benefit each patient individually gets from our practice. The difficult patients who are either non-compliant or have complexities that make the standard protocols inappropriate for them are the very patients who most need a good primary care doctor who individualizes care. The easiest way to meet numerical targets is to run off the pateints who don’t help your numbers, while keeping those who do. P4P may punish “bad” doctors. It will also punish “good” doctors who are patient with the more difficult patients. The best way to avoid having the data being misused by idiots is to not collect it.
It reminds of the story of how Hong Kong remained a free market even as the governing authority, Britain, descended into impoverishing socialism. The Governor shrwedly refused to collect economic data, without the data, the beurocrats could not scratch their itch to control and regulate.
“how can anyone take seriously this issue of noncompliant patients if the doctor himself doesn’t even know how many noncompliant patient he has in the first place?”
I don’t get it? I have Joe in my office and he didn’t take the ACE inhibitor that I prescribed. It could be any one of several reasons, not all demanding a fix from me. But how does the appropriate management of Joe turn on whether I have 10 other diabetics not taking an ACE inhibitor, or 100? What does that have to do with his proper management? And why should my reimbursement for Salley next on my list, hinge on whether Joe takes his meds or not?
I read the article. It was very positive about P4P. It noted that cherry-picking was a possibility, but talked intelligently about designing systems to minimize that issue. It was Kevin who cherry-picked a single quote that was perhaps the most negative in the entire article. I have watched the evolution of Kevin from a basically fair commentor with some biases to a spinner willing to distort almost anything and use the most biased sources (Fraser Institute) to further his agenda.
“Come on now, lets be real. The “health status” of my practice?…”
There is a famous truism, “if you can’t measure it, you can’t manage it.” Ths truism applies in medical practice as it does in any other industry.
As physicians, to see for ourselves how good we are doing (which is a good thing, isn’t it?), shouldn’t we know our own practices’ clinical metrics (even if we were to leave it private information). Don’t you think it would make you a better physician if you knew, how many of your 3000 patients are not taking an indicated statin, and why? Come on, you know who owes you a copay. Why is that any more important?
I think this is more fear of looking in the mirror, rather than falling on the age old defense, “each patient is different and standard cook book protocols don’t apply.” That may often be the case, but you should know which and why at anytime.
“But how does the appropriate management of Joe turn on whether I have 10 other diabetics not taking an ACE inhibitor, or 100? What does that have to do with his proper management?”
Scientific standards have already identified who should be on an ACEI. If you have 1 who doesn’t take it – you should at least know know why and have it accounted for. If you have 100, then either your treatment decisions or your patient communication skills are more suspect, and you should carefully identify why.
“And why should my reimbursement for Salley next on my list, hinge on whether Joe takes his meds or not? “
It shouldn’t. But those that pay for this care, the employers and gov’t, believe that there is much room for clinical improvement. And in there search for measuring care delivered, they will measure the health status of your practice, even if you don’t.
And if you have 100 patients not on an ACEI, and your only defense is “my profesional judgement” than maybe you should consider taking a few more CMEs.
If you can’t measure it, you can’t manage.
With P4P what does it matter if your patient is compliant or not? Your documentation will show that you prescribed an ACE so you meet their “targets”. As with everything in medicine it doesn’t matter what you do anymore, its how you document is all that matters.
I’m wondering what a litigious patient “smells” like? There seems to be a certain breed of physicians who visit and comment on this blog. You are a sad lot really.
Drs. who don’t want to treat the patients who probably need them the most…Seems like an oxymoron to me.
Why not just hang the rules on your door..”If you are obese, diabetic, have HBP, can’t afford the 2,000.00 per month worth of prescriptions I will write for you… or… basically if you are, in any way, in need of medical care, you DO NOT qualify for my services.”
That should just about cover it. I’m starting to think that many of you have absolutely no confidence in yourself as a medical professional. Your way of handling it is to only want to treat well people.
Anon 4:48-
Compliance matters because often the measures of P4P are made based on claims data. Therefore, if I prescribe a medication but my patient does not fill the prescription, there is no insurance claim. In the eyes of the insurer, I didn’t do my job. Trust me, the insurers are not reading my progress notes.
I’ve already run into problems with this. For example, I’ve been penalized for not performing a pap smear on patients who have had a total abdominal hysterectomy. The TAH is noted in the chart, but there of course is no claim. Isn’t it great? I save the insurer money by not performing an unecessary test, and I get penalized.
Good system.
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