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.

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?

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?

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.

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.