Reforming the physician payment system to focus on health outcomes is an idea common to most plans.
The more fundamental question is whether paying doctors more to meet quality measures actually benefits patients.
So far, no definitive data suggests that’s the case. Jason Shafrin points out that the rewards in current pay for performance proposals pale in comparison to the UK, where the average physician practice earned $133,200 in reward-based payments. This results in “little behavioral impact” for American doctors.
Furthermore, he cites a study which suggests that paying doctors for outcomes simply leads to better documentation without consistently improving patient care:
Is P4P rewarding doctors who have rich patients that see the doctor often? Is P4P rewarding doctors who document care more accurately? Or is P4P really improving the quality of medical care?Because P4P is such a blunt instrument, policymakers and insurance companies cannot answer these questions.
Policymakers don’t appreciate the nuance and unintended consequences surrounding pay for performance initiatives, and fail to acknowledge that there is little data concluding that paying for quality improves patient care.
topics: pay for performance, patients
Related posts:
- Does pay-for-performance work, and will it improve health care quality or patient outcomes?
- Why today’s quality measures do not improve health outcomes
- Consumerism and health quality
- Quality measures
- Quality and safety are not the same thing
- Electronic medical records: Expensive . . . and ineffective?
- Restricting resident work hours forces doctors to lie, and other unintended consequences of the 80-hour work week
{ 3 comments }
P4P, as described above, will not work because there are too many layers separating money from the patient. In a more direct transaction, input is quite rapid: “You did a poor job, you won’t see a dime more of my money”, or, “You did a great job, I’ll mention your name to those I like.”
And yes; very important question. When chosing what to measure, do they chose those things that count as performance in the eyes of the patient or the insurer?
Kevin, Jason —
Consider the Premier HQID Demo as a counterexample.
“[I]f all hospitals nationally were to achieve the three-year cost and mortality improvements found among the HQID project participants for pneumonia, heart bypass, heart failure, heart attack (acute myocardial infarction), and hip and knee replacement patient populations, they could save an estimated 70,000 lives per year and reduce hospital costs by more than $4.5 billion annually.”
– from Premier press release.
See my post on this with links to Premier (and other posts, of course) at:
http://healthblawg.typepad.com/healthblawg/2008/02/premier-hqid-de.html
I have a different problem with P4P: By necessity, a P4P project focuses on a handful of indicators, and then directs $$ to top performers. Thus, other significant indicators are possibly given short shrift by providers, and the providers who don’t do as well on the indicators of interest get paid less and may devolve into a death spiral of sorts.
Bottom line, some P4P programs really do work, but if you look beyond the boundaries of the program, you will likely see some unintended consequences.
Little discussed but also important are the P4P metrics that are patently unrelated to patient health yet quite prevalent — the one that comes to mind is the brand-to-generic ratio. Usually listed under the “efficiency” elements of P4P, but included in the overall algorithm that ultimately determines monetary benefit. Patients should be informed, then outraged, by such an incentive system is clearly fraught with conflict of interest.
Tom from Boston
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