Why patients should be paid for good health

Over the past few years, insurers and Medicare officials have fostered the idea that physicians should be reimbursed on a pay for performance (P4P) basis.  Many articles, both pro and con, have been written regarding P4P.  I have been strongly opposed to P4P, believing that the sole purpose of the performance indicators designed by the government and insurers is to reduce payments to docs and hospitals.  I also believe that the establishment of performance guidelines will lead to the mechanization of medical care as physicians and hospital administrators will learn what they need to do to “perform” and practice guideline-based medicine as opposed to providing personalized care.

Recently, I have reassessed my P4P stance and believe that a system that pays patients for performance could work.  Yes. “patient pay for performance (PP4P)” would be a good thing.  As I envision PP4P, patients would be given performance guidelines and be graded on adherence to treatment plans, consistency in taking medications, participation in timely follow up visits, weight loss, and appropriate exercise.  Of course, there are many other performance standards that could be set for patients depending on what ails them.

A diabetic could be graded on his/her blood sugar control.  A patient with hypertension could be graded on his average blood pressure.  An obese patient could be graded on continued weight loss.  Paying patients for performance makes a lot of sense.  All we need is a grading system.

If getting an “A” on your blood pressure control made money for you, wouldn’t you be more likely to control your BP?  If getting a “D” on your blood sugar control cost you money, wouldn’t you strive to get a better grade at your next visit?

PP4P already exists. Yes, controlling your blood pressure and blood sugar already saves you money.  Complying with your treatment plan and managing your disease saves a lot of money.  If you think your BP meds are expensive, wait until you see the bill for your first heart attack.  Complying with your treatment plan saves you money by keeping office visits and medication to a minimum.  Reducing risk factors, modifying diet, and exercise may even prevent you from future healthcare expenses.

Yes, PP4P works.  It would work even better if your government and insurers would pitch in.  If your insurer would reduce your premiums for an “A” performance, wouldn’t you be more likely to work for an “A?”  Of course you would.  If Medicare would pay recipients for good health by reducing deductibles and co-pays, wouldn’t they save money in the long haul.  I would think so.

I’m working on a grading system for my patients.  It’s time to institute PP4P.  It’s time to grade patients so that those with low grades can realize the errors of their ways and have a chance to improve their performance.

Stewart Segal is a family physician who blogs at Livewellthy.org.

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  • http://www.HealthEconomicsDigest.com/ Health Economics

    What about charging them for putting on weight or not controlling their blood sugar levels? Its a completely valid concept when resources are finite and healthcare already costs so much.

  • dontdoitagain

    OMG!  Are you kidding me?  Patients are now children to be graded and harrassed about things.  Give me a break.   This is the most patronizing thing I have read in a long time.  Can patients charge their provider for giving them drugs that do more harm than good?  I’m thinking of statins and Fen Fen while I write this.  Every single one of the drugs to control cholestrol, weight, bp has a long list of serious side effects…  How nice that FORTUNATE people with good health can be rewarded.

    As for “Health Economics,” you seriously  think that charging patients more money is a good way to combat health care costs?  To whom does this money flow?  To the physician?  To the government?  Do you want more people NOT to have access to health care?  If you are wanting people NOT to be able to be treated, this is a damn good way to make sure that the people who need medical care most will shun their providers!  That’s the plan?  What resources are finite?  It’s the health care MONEY that’s finite isn’t it, as there are plenty of providers.  Are you saying that the patients are expendable if they can’t control their weight or blood sugar levels?  Who gets to pay for the blood work in order to monitor the blood sugar levels?  Are you aware of all the problems with weight control ideas?  How many people have died because of stomach staples?  Gall bladder removal as a direct result of this surgery?  Fen fen deaths?  Use your head!

  • http://dinosaurmusings.wordpress.com/ #1 Dinosaur

    Your proposal suffers from the same fallacious reasoning as physician P4P: the assumption that things like blood glucose control and blood pressure are entirely within a patient’s control. Even things like weight loss and smoking cessation are far less straightforward than many people — primarily the naturally thin and those with no addictive tendencies — are willing to admit. Realistically trying to implement any kind of system as you describe will indeed result in nothing more than fortunate patients reaping a windfall

  • http://twitter.com/livewellthy Stewart Segal

    I couldn’t agree with you more.  P4P and PP4P are ludicrous but it is where Medicare and the insurers are going.  I’m sorry you saw this article as condescending!  I only mean to inform my patient as to the future trends in medicine.
    Corporate America is already implementing PP4P.  I am getting a steady stream of forms from employers seeking medical information for which the employee, if he does well, will be paid a bonus.
    The real PP4P is in feeling better and being healthier.  Of course, when a patient controls his disease with lifestyle modifications, he saves a lot of money as well.

  • http://pulse.yahoo.com/_UDJTUH45CFUC6LKCBLB6FGRDKU Diane

    I would love to be healthy. I grew up with asthma, can’t help that – unless I live in a bubble – since it’s that nice fresh country air (was out walking today and someone else cutting his grass triggered it then at my son’s lacrosse game playing catch (baseball) with my other son and being out in farmland triggered a 2nd attack). Getting pregnant triggered chronic migraines when I’d never had a problem with headaches prior to that. More recently, a DVT and kidney stones have led to a series of health problems that now includes heart failure. When does it end? Honestly, I’m sick of being sick! A couple of weeks ago I told my cardiologist that this summer I just want to make it to 2nd base (softball season starts soon) without gasping on the sidelines like last summer.

    Oh, but did I mention that I’ve always exercised since I was a kid. I eat healthy and feed my family healthy (we are ALL thin and lean). My kids play sports of their choosing, I send them outside to run around, ride their bikes, etc. Sadly, one son inherited the migraines (a long line on my mom’s side we’ve learned) and one son has asthma. 

    Should my family be punished for this? I really appreciate that many of the problems people create are self imposed. Heck, I love some good old Wendy’s french fries and Cheetos as much as the next guy. And when the hormones are crazy or the kids were toddlers, a brownie sundae from my favorite ice cream shop was just the ticket. But just like dontdoitagain said, not all health problems are of our own doing. My husband is remarkably healthy and happily, his job / insurance rewards him for his efforts. But he has a strong family history of early cardiac death on his father’s side and cancer on his mom’s side. He was born with those genes and while I will do my best to feed him well and encourage him to keep walking and jogging, until that genetic transfer is available, I can’t change his unknown odds.

    I work in the business. I know what people do to themselves. But I also know that some people are high users of medical care thru no fault of their own and they are thrown into this big vat of “bad” people. Accidents, illnesses, inherited conditions, bad genes, or just plain old who knows why your body is rejecting you – these are all things we can’t control. Big government will never separate the naughty from the can’t help it. 

  • Dorothygreen

    Pay patients for performance is unfair.  It is unfair to the person who have  illness not linked to addictive behaviors.  It is unfair to the taxpayer who works hard keeping themselves healthy.  The greatest problem in the US bare none is our perverse eating culture - the SAD (Standard American Diet).  

    So some company CEO mentioned that PPP in his company reduced obesity and sick days and it became part of the health care bill.  Did he use his own money to do this?  If he did, good for him (or her).  Did the person(s) accepting this as a valid method ever consider who will pay?  I sure don’t mind people who develop a disease through no fault of their own being in my risk pool (this is what insurance is for) because that might happen to me.  You will hear this from citizens in all other advanced countries – a solidarity that is is akin with providing for the general welfare.  NONE would trade their system for our unfair hodgepodge even if they have the money to go to some other part of their country, or another country for a procedure.   

    A smoker can be charged a higher premiums because tobacco is recognized as an addictive substance.  The smoker has to pay a high tax on cigarettes and be confronted with a strong message about the RISK of tobacco smoking.  The smoker is provided with treatments and access to counseling for this addiction.  In 40 years the percent of smokers has dropped from 65% to 20%.  Guess what the studies show – the ever increasing tax has had the highest impact on quitting.   

    We have a RISK (Reduction In Sickness) model,  We know that sugar, fat and salt are addictive to humans (and rats, and the other animals that eat the SAD).  We know that most of the sugar, fat and salt we consume is in highly processed foods which are pervasive and cheap (subsidized).  The world knows it .  Other countries see it affecting their health care budges.  Other countries are acting by using RISK tax and VA tax as a strong message.   And their rates of overweight and their health care costs are way below those of the US.  WE DESPARATELY NEED HEALTH REFORM. We do not need PPP.  Reforming our Eating Culture is Critical to Health Reform.  It is a public health problem that threatens the stability of the US’ future.   The reforms need to be implemented from farm to fork.  

  • Emily Lyons

    This will hit many patients with mental illness hard, who followed their doctor’s orders and took their medications, often for atypical antipsychotics and other psychotropic medications, and gained a lot of weight and maybe even became diabetic. Perhaps we can send the bills for increased premiums to our psychiatrists.

  • Kathy90277

    I am appalled by this.  I have several things wrong with me and let me to tell you…I have never smoked, not a drinker, BUT according to ALL doctors who have seen me…I just have bad genes.  I eat veggies, and I take care of myself the best that I can.  Having said all of this, stress is a huge problem for me and causes problems with my blood glucose.  Yes, I am type II but so was my dad, and all his brothers.  I am not a big woman.  My weight fluctuates.  Medication tends to add weight like estrogen…antidepressants etc.   So, now what?   You want to discipline me and make my life harder than it already is?  I have PN, DDD (Disc disease), Type II Diabetes, Fibromyalgia, Sleep Apnea, Chronic Statis Dermititis, Venous Insufficiency, Hypothyroidism.  I have been seen by some of the best doctors.  My mother died at 66.  Both legs amputated (cardiovascular) and bladder cancer.  Sometimes people can’t help it when it comes to their health for goodness sakes.  I will go to Congress and talk to them if I have to.  This is simply DISCRIMINATION and very sad.

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