A comment on pay for performance


Category : General, Medical Rants, Politics

Due to the huge amount of spam comments that I receive, I occasionally do not approve a comment. This rarely has anything to do with content, rather browsing through 400 spam comments, I might miss your real comment.

This comment is worthy of consideration:

Tried to post this to the pay for performance post but it did not seem to stick.

As a reader from the payer side, I have a slightly different perspective. Before you discard my comments and jump to an inappropriate damning because I come from the “dark side”, read and consider.

1. All the comments about quality etc. above do not reference outcomes – did the patient’s functionality improve and stay at a high level during/after the physician’s care? All the talk about infection rates, use of aspirin, beta blockers are PROCESS measures not OUTCOME measures. As such, they play no role in a discussion about “pay for performance”, unless one equates performance with process.
2. Physicians will continue to find themselves micro-managed by payers until and unless they can define their success as delivering outcomes, defined by improved functionality. The reason is simple; if you don’t have any concept of an appropriate output, the argument degenerates into meaningless disagreement about inputs.
3. The notes above about “quality” care are anecdotal and emotional, not quantitative. Therefore they do not add to the discourse. “I believe the quality is better” is not helpful – what statistics do you have to demonstrate that quality is in fact better? Do patients live longer? Are they able to perform the ADL at a higher level than a case-mix adjusted population? Where’s the proof?
4. Re Dr. Lacsamana’s comments on physicians being able to affect positive changes – I must agree with his statements. The California Workers’ Compensation Institute’s (www.cwci.org ) analysis of workers comp claims clearly indicates that physicians who treat a larger volume of comp claimants have lower disability duration, lower medical costs, and faster return to work. Now THOSE ARE OUTCOMES.

I have bolded a mistaken assumption in the commenters argument (his overall argument is reasonable, although not completely knowledgeable). The reason I (and others) choose these “process” measures, is precisely because adherence to these process measures demonstrably improves outcomes! The commenter is correct that we need outcome measures. What we truly need are process measures (because the numbers needed for outcomes are staggering) shown to improve outcomes.

Some concepts in quality are much more difficult to quantitate. That continues to be the crux of my argument. The other day on rounds I counseled a heart disease patient. I spent 15 minutes explaining to this 50 year old with 3 stents why his medications and smoking cessation were so important. We discussed the rationale for each of his meds.

He told the intern the next day that my session represented a breakthrough in understanding. He had been prescribed all the correct meds, but never was told why they were important.

How do we quantitate the extra 15 minutes that I spent with that patient educating him. He felt that the session was very valuable. I believe (but then I am an optimist) that our session will make a difference in his personal process of care – and therefore he will have a better long term outcome living with his heart disease. But I do not really know. How can we fit that type of session into pay for performance?

Given the diversity of patients, diagnoses and complaints that we handle daily, I have doubts about the correctness of any pay for performance measures. But then, we will have to see.

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Comments (10)

I have some serious concerns, as a physician, about pay-for-performance.

When outcomes measures are used, there are many variables outside of the physicians control. These make the actual “performance” as measured by whatever means, highly patient dependant.

If we look at outcomes measures – i.e. less lost work, less sick days, less hospitalizations, lower costs, whatever, and then rate physicians based on these outcomes, physicians will be incentiviezed to select for patients likely to have good outcomes. The 55 year old, history of 2 MIs, diabetic, who refuses to quit smoking and eat twinkies is not a patient I would want on my panel. Their outcomes will be bad, and negatively impact on my “performance.”

On the other hand, if you rate performance based on things such as: physican recommended smoking cessation, physician recommeneded aspirin, i.e. things that can be studied and measured and which the phsycian can do (rather than hoping the patient will do), at least there is some consitency. With true outcomes measures, two physicians with identical methodology, philosophy, and recommendations will have very different “performance.” The physician will be penalized for the patients behavior.

I agree with Rich about the difficulties in quantitating outcomes for patients. Pay-for-performance sounds nice as a concept; implementing it to make sure it does what it’s supposed to do remains unsettling to me.

As noted, we deal with patients with unpredictable responses, both biological and behavioral, to whatever we advise and give them for treatment. That diversity is what makes the road ahead for pay-for-performance an “iffy” venture. And who will be responsible for monitoring the outcomes for these patients? It seems to me we would be adding another layer of bureaucracy to a system already riddled by so many requirements it may not be worth the time needed to make it go.

As a primary care physician (general internist), I have always felt that the time the doctor spends with the patients, and the way he deals with their problems, would be lost in the focus on “outcomes.” The example of Dr. Centor in spending 15 mintues with his patient to explain the rationale of why he is being given his medications and what he is expected to do may not register on that outcome index. The caring and personal touch of the doctor would be submerged by cold statistics.

I think most physicians would have no problem adopting practices derived from evidence-based medicine. But PFP, at least in my opinion, remains dubious with so many uncertainties.

As the source of the original quote above, I must disagree with the premise of some of these arguments. Dr. Centor, my point is precisely that you, as the physician, know best what to do with each and every patient. So, measuring process, defined as things you do, is not helpful. To quote Dr. Lacsamana, “The caring and personal touch of the doctor would be submerged by cold statistics.” Absolutely true, and that is my problem with process measures – we can only say “well, he didn’t do enough counseling, he should have done this or that” – but we weren’t in the room, we did not have the conversation, we don’t know the signs and symptoms, or myriad other contributors to the “outcome”. We do not know what you should have done. Therefore, the fairest way to assess performance is not measuring what you did, but what were the results. I don’t want the health insurance plans that are my clients telling you what to do, I want them to figure out which doctors have the best outcomes and send patients to those docs.

If you want to stand on your head and tell knock knock jokes to one patient and administer oxycontin to the next, and both patients improve and become more functional, who am I to say “that’s bad medicine” – I am not the doctor, and if that is what you need to do to treat the patient, and if the patient gets better, great.

As to your point about “process demonstrably improves outcomes”, what outcomes? what is your basis for that claim? what evidence do you have that doing a certain procedure, test, therapy produces a higher level of functionality, a more productive person, a “healthier” individual? The “outcome” that matters to your patients is that you improved their health, their ability to function, their independence. The “outcome” that matters to the employers that are paying (albeit grudgingly) your bills is employee functionality and productivity.

I have worked extensively in the area of medical guidelines, clinical criteria, disability duration guides, and I have seen very few attempts to link medical care to functionality, productivity, or ADL. Sure, there are a few, but they are far between.

Finally, to the issue of case-mix adjustment – yes it is difficult; yes it is fraught with problems, but payers will not let that hinder their efforts to identify the top performing physicians and send patients to them. And they are working hard on case-mix adjustment techniques and methodologies because most recognize that patients ARE different.

Would you not rather be evaluated based on your results than on whether you complied with some “medical director’s” idea of appropriate treatment?

I agree that case-mix is a problem. More to the point, a physician can self-adjust his own case-mix to ensure that on average, his outcomes are better by selecting patients that he/she feels are more likely to be compliant, have less complex profiles, etc. Unfortunately, some patients will find it difficult to find a physician who is willing to allow his case-mix to deteriorate by accepting them as patients.

I’m looking forward to the success of outcomes-based medicine–its time has definitely come. However, reading the comments above, I picture this: a harried physician caught between crafting a tailor-made treatment plan and a backed-up office schedule, while the payor stands there in a green eyeshade with a clipboard and a checklist. Meanwhile, the patient sits there like a confused, passive outsider.

The patient MUST become a more active participant in his care, and he deserves our help. 15-minutes of bedside counseling may have been a breakthrough for this 55 y/o diabetic smoker; but it took him 2 MI’s to get it!

How do we teach every patient the rationale behind their treatment to ensure their compliance? What will reach them?

[…] eeds certain as-yet-unspecified quality indicators. The medical blogs, such as Medpundit, DB’s Medical Rants, and Galen’s Log, have been discussing this […]

[…] t quality measures are chosen. All physicians know that much of quality is immeasurable – A comment on pay for performance. Nonetheless, whether the ACP (or any […]

All of this is pointless. The insurance industry and government want to use “P4P” as yet another hammer to denegrate and destroy medicine. It will be an arbitrary weapon to punish– not to promote– practices. We have an environment of unmitigated hostility towards physicians from private insurance and Medicare. It’s over, people- stop even trying.

how about this — patients get to review the eobs. If a patient is delighted with dr x, patient can provide a rating that will up doctor x’s reimbursement rate by 10% or whatever. If patient is unhappy with dr x, patient can downgrade doctor x’s reimbursement by 10%. If doctor x blows patient off and patient x has to go to second doctor for same problem, and patient complains, doctor x can get 75% of visit cut from payment. Why should Dr X get paid for no value added and time away from work? If patient reports that doctor took 45 minutes for a complex issue, shouldn’t that matter in p4p — if doctor breezed through in 2 minutes, didn’t pay attention, and is asking $400, shouldn’t the patient get to turn off the tap? Isn’t the real measure of performance if the patient finds themselves better? Or treated appropriately and with dignity? patients are not so dumb to that they haven’t figured out the pay for procedure gig and have figured out that they mean zero in the process. Doesn’t this address both quality and efficiency — no patient wants to get dragged all over the place with tests and medication they don’t need, but nobody wants to stay sick when they don’t need to either.

If SOMEONE would then publish even minimally reliable data on the doctors, (how many procedures of what kind, how many failures, what percent are complex, level of patient satisfaction, etc. patients could steer themselves to docs whose practices are appropriate to their needs (and not be referred to someone’s golfing buddy), good doctors would prosper, bad doctors would become drug reps and we would all be happier.

Is it not the patients' responsibility to questions his/her medicines? Is it not also the Dr.'s responsibility to clearly explain, taking the necessary time , to make sure the patient understands their care?  If all Dr's  took the time you do, patient care would lead to better health AND better educated patients, 

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