Pay-for-performance is all about cost control

If you read my articles, then you likely know about the scam known as pay-for-performance (P4P).  This program not only fails to deliver on its stated mission to improve medical quality, but it actually diminishes it.

In short, P4P pays physicians (or hospitals) more if certain benchmarks are met.  More accurately, those who do not achieve these benchmarks are penalized financially. I do not object to this concept.  Folks who perform at a higher level should be rewarded accordingly. My objection is that the benchmarks that have been selected are arbitrary and too far removed from true medical quality measurements. Benchmarks have been chosen that are easy to measure even if these measurements don’t count for much.  In other words, what really counts in medicine, isn’t easy to count or measure.

Consider the following physician vignettes:

  • A surgeon advises against proceeding with surgery as he feels that in 48 hours recovery may begin.
  • A pediatrician makes a series of phone calls to arrange for a social worker to become involved in a challenging home situation.
  • A family physician tells a patient that a CT scan is not necessary for his condition.
  • An internist recognizes that a patient’s new symptom is a side effect of a recent medication, which he stops.
  • An emergency room physician sees a patient with a cough and notices a suspicious mole on the patient’s back.  He sends the patient to a dermatologist.
  • A gastroenterologist carefully palpates a patient’s abdomen and discovers that the spleen is enlarged.  This begins a path that leads to an unexpected diagnosis.
  • An internist takes a thorough medical history letting a patient tell his story without rushing him or cutting off his responses.
  • An oncologist doesn’t advise futile cancer treatment, even though it could be presented to the patient and family in a manner that they would accept it.
  • A hospitalist communicates all relevant medical information, including unfinished or pending issues, to the internist who will be assuming care of the patient after hospital discharge.
  • A psychiatrist saves a patient’s life who had contemplated ending it.

These examples illustrate what I think is very high quality medical care.   But, since there is no way to reliably measure them, they don’t count in the P4P schema.  So instead, the government and insurance companies will measure lots of dumb stuff and then dock us when we don’t measure up.

This has nothing to do about real medical quality, but it has everything do about cost control.  If the P4P enterprise were paid on its performance, they would be out of business.   Shouldn’t they have to be subjected to the same rules that they impose on the medical profession?

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower

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  • Dr. Drake Ramoray

    Pay for performance is bad for the poor and the doctors who care for them.

    The Brits discovered three years ago that pay for performance doesn’t improve outcomes. Got to love the title. So Time magazine

    And with no little sense of irony, The Toxicity of Pay for Performance (yes the actual title) written by none other than Donald M Berwick MD the recess appointment of CMS.

    1) the supervisor is now the customer (ie you now work for the third party)
    2) it is hard to collect all of and the right information
    3) it increases internal competitiveness (doctors jockey for healthy patients or move to affluent areas.)
    4) it costs a lot to administer
    5). It is inescapably unfair
    6) it reduces intrinsic motivation
    7) it slows change (see recent changes in cholesterol guidelines)
    8) it is disrespectful of human relationships

    Well golly, lets implement it on probably the most complex and important human endeavor on the planet!

    • SteveCaley

      As part of 3) it endorses perverse incentives – things that do nothing to improve something, but make it look better.

      There is also moral hazard – risk displacement, or blame-shuffling. If I keep all the profits, but you bear all the risk, what does that do for the enterprise?

      • Dr. Drake Ramoray

        Exactly. On another post I pointed out that in addition to the the diminishment of the profession that the physician gets to retain all the liability while still working under the “efficiency” constraints of being an employee.

        • ErnieG

          To expand on that further, I think at least three things will need to happen for physicians to survive into the system of Corp Med.
          1) Unionization
          2) Malpractice reform to shift liability to ACO/Insurances, or at least away from physician as individual healer to manager of populations.
          3) A profound change in the ethical obligations of physicians, from obligation to patients to obligation to the state/insurer/hospital.
          I do not believe these are good things, but lets face it, the idea physicians can act or be professionals in a system that does not treat them as such is bound to destroy any sense of professionalism. I think medicine is dying.

          • SteveCaley

            The ultimate liability target is the patient, and it is neither fair nor pretty. That is what is behind all the “patient-centered apps.” You roll the dice, you took the bet.

  • DeceasedMD1

    Well it worked famously for the VA.

  • Arby

    Which is reason number 2 that others should not pay for your routine health care.

    Also, I disagree with the readmission being all the patient’s fault. Too many variables involved, and yes, I worked in a hospital.

  • SteveCaley

    It is not P4P, but should rather be called C4C – cash for conformity. Monolithic bureaucracies prefer homogenous mediocrity, applied universally without deviations. Even to the bureaucrats, UEF (universally enforced mediocrity) has a sour ring to it, so they prefer Best Practices.
    Who can argue against Best Practices? Except when they put on the white robe, and pretend to be Universal Truths. The best course for the physician to take is the most common course, except when it is not. Such things trouble the bureaucratic mind – in spite of our brilliance in programming, we cannot program each of the Borgs to reason independently.

    The universal secret password of mediocrity is the myth of the norm. The ideal statistical function, they pretend arrogantly to know, is the single spike – the undeviating uniformity. The “standard deviation” is the only other statistical distribution which they can recognize, although not in the least understand. Such bureaucrats consider deviation of a point from a norm to indicate its inherent inferiority in standing – the weakness of the provider, for instance. What is normal is normative, so assert the Borgs. You shall be ranked, you MUST be ranked so as to produce a 5% Deviant Population. Those are the Rules of the System. If they are nonsensical and mad, so be it. They have a nice ring, don’t they?

    • Arby

      IDK. I think I am much more cynical than you. Mostly it is about pushing numbers around so that too many don’t get paid too much…in their minds. Sorry, but somehow in “pay-for-performance” land, I just can’t believe that they want all their physicians to be top performers.

      Or, maybe you are saying what I am saying and it is just too late for me to think clearly.

    • ErnieG

      You are starting to become my favorite. It is very clear to me that medicine will soon no longer be about helping an individual’s struggle against their disease, but rather managing population statistics. The third parties involved know nothing about what it means to practice medicine, and they are making it into something which will be horrible.

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