Cardiologist-author Sandeep Jauhar with another excellent piece in today’s NY Times, where he eviscerates the P4P movement.
When non-clinical policy wonks try to regulate physician behavior, unintended consequences invariably arise. This often worsens the situation:
Whenever you try to legislate professional behavior, there are bound to be unintended consequences. With surgical report cards, surgeons’ numbers improved not only because of better performance but also because dying patients were not getting the operations they needed. Pay for performance is likely to have similar repercussions.
Jauhar points to the 6-hour antibiotic rule for pneumonia. Many patients are given antibiotics unnecessarily before a diagnosis is confirmed. This can lead to serious complications like C Difficile colitis – which happens to be on Medicare’s “no-pay” list.
Thus, physicians can be placed in a position where they are rewarded for giving antibiotics early, but penalized for the complications that arise from that incentive.
Also perplexing is who should receive the bonuses, as the average Medicare patient sees over five doctors annually:
Care is widely dispersed, so it is difficult to assign responsibility to one doctor. If a doctor assumes responsibility for only a minority of her patients, then there is little financial incentive to participate in P4P. If she assumes too much responsibility, she may be unfairly blamed for any lapses in quality.
The bottom line is that there is no evidence that pay for performance even works, and there is plenty of potential for patients to be harmed.
Medicine is highly nuanced, and what seems like a superficially good idea, often isn’t.
Related posts:
- Pay for performance unintended consequences
- The unintended consequences of P4P
- Extreme pay for performance
- Meant to be broken?
- Non-compliance
- Good in theory, bad in practice
- Medicare pay for performance, what went wrong?
Scrubs
{ 2 comments }
I can’t remember if it was Pennsylvania or New York that started the quality rating for cardiac surgery. In that same time period there was a large increase in referrals from that state to the Cleveland Clinic for cardiac surgery cases. Bottom line is that it doesn’t look good to operate on the sickest patients so transfer them to a regional center. That is just great for the patient and their family.
Interesting article…but where’s the “but-for” evidence that the 6-hour antibiotic rule led to this patient’s C. diff? That’s right; there’s none. In fact there’s never been a study showing adverse patient outcomes due to the antibiotic timing rule, even at 4 hours. The best anybody’s been able to come up with are 2 single-institution studies suggesting diagnostic inaccuracy. But in the context of a national reporting program, single institution studies are just anecdotes. Institution-level decisions (and plain old random variation, since dozens of unpublished institutions probably looked into similar data) dominate institution-level results.
Of course, in the NYT, you don’t even need an institution…a single patient will suffice. I once had this patient whose gout stopped bothering her after the Sox won the world series. Clearly baseball works!
Evidence (or lack thereof) may not change minds here, but isn’t it worth thinking scientifically about P4P? Why not treat P4P like any other medical intervention and wait for the results to come in before pre-judging it?
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