P4P – some data

3

Category : General, Medical Rants

Early Experience With Pay-for-Performance (from JAMA – subscription required)

Context The adoption of pay-for-performance mechanisms for quality improvement is growing rapidly. Although there is intense interest in and optimism about pay-for-performance programs, there is little published research on pay-for-performance in health care.

Objective To evaluate the impact of a prototypical physician pay-for-performance program on quality of care.

Design, Setting, and Participants We evaluated a natural experiment with pay-for-performance using administrative reports of physician group quality from a large health plan for an intervention group (California physician groups) and a contemporaneous comparison group (Pacific Northwest physician groups). Quality improvement reports were included from October 2001 through April 2004 issued to approximately 300 large physician organizations.

Main Outcome Measures Three process measures of clinical quality: cervical cancer screening, mammography, and hemoglobin A1c testing.

Results Improvements in clinical quality scores were as follows: for cervical cancer screening, 5.3% for California vs 1.7% for Pacific Northwest; for mammography, 1.9% vs 0.2%; and for hemoglobin A1c, 2.1% vs 2.1%. Compared with physician groups in the Pacific Northwest, the California network demonstrated greater quality improvement after the pay-for-performance intervention only in cervical cancer screening (a 3.6% difference in improvement [P = .02]). In total, the plan awarded $3.4 million (27% of the amount set aside) in bonus payments between July 2003 and April 2004, the first year of the program. For all 3 measures, physician groups with baseline performance at or above the performance threshold for receipt of a bonus improved the least but garnered the largest share of the bonus payments.

Conclusion Paying clinicians to reach a common, fixed performance target may produce little gain in quality for the money spent and will largely reward those with higher performance at baseline.

One underlying principle of the pay for performance movement stems from the belief that we can use incentives to improve adherence to evidence based quality indicators. The crux of evidence based medicine (EBM) follows from an examination of high quality data. EBM eschews belief.

This study tries to understand how P4P might influence physician practice. It finds no positive impact. Rather P4P may simply be a scheme for rewarding high performers.

Perhaps that is the desirable outcome. Perhaps P4P will just recognize those who already function at a high level.

However, as I hear the debate, most proponents see P4P as a means to improve quality. This article argues against that.

We must continue to collect data as we evaluate ideas, even if those ideas are compelling. Hopefully, politicians, insurers and organized medicine leaders will heed this study and others to follow. We do not need a “magic bullet” unless we can be certain that the magic bullet works.

I am currently listening to Freakonomics. While I have only listened to the first third of the book, one transparent message invokes the challenge of externalities. We must carefully understand how P4P will impact medical care delivery. To rush down this path without knowing where it goes seems unwise.

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Comments (3)

When they are talking about pap smears and mammograms, do they mean the accuracy in reading or just plain percentage of patients who do it? If it is the latter, wouldn’t paying doctors more if higher percentage of women is screened, make the doctors try to order more tests by any means necessary? For example, to get the numbers up, a doctor will be more likely to “forget” to tell a low-risk woman that after 3 consequitive normal pap smears, it is OK to do them less often than once a year? Or to continue to do pap smears on women after hysterectomy simply to get the number up?
Or pressuring and harrassing and cajoling an informed 40-something women who after careful reading of all available materials on mammography (published papers with both for- and against- opinions, rapid responses to these papers, USPSTF report, PDQ summary of evidence) and after consideration of both absolute probability of individual benefit and probability of individual harm (I am talking about overdiagnosis/overtreatment and how it affects the incidence) and her personal values decides that she doesn’t want to have mammograms?
It seems to me that this type of pay-for-performance will be yet another incentive (in addition to the fear of law suits) for doctors to “forget” to inform the patients about the risks of screening tests, and to provide misleading information about possible benefit by for example a) citing life-time risk of the desease if every woman lives until the age of 90 instead of her 10-year risk b) giving inflated and largely meaningless relative benefit numbers instead of accurate absolute probability c) using only studies that showed higher probability of benefit as an example and ignoring those that showed no benefit d) just calling the woman “irresponsible” because of the choice she has every right to make.
It scares me as a patient that this type of P4P will perpetuate the current mindset that patients have to be persuaded and cajoled and scared and harrassed to undergo screening.

On a simpler note, this will lead to more check list medicine. Set a standard and the doctor will just do what is needed to meet that standard regardless of the need.

Turning 50 has been a real experience since I now seem to need a laundry list of meds. When my labs do not indicate a need for the meds, the doctor wants more labs, and the problem is, the insurance company will not pay since there is no need. We wasted 5 minutes on why I felt I did not need or want a tetanus shot. Simple, my choice.

P4P is a good concept, it just needs to be refined to allow for some flexability and real world situations.

Regardless of its effect on improving practice, I do thinks it’s a good idea to reward those who do a better job by paying them more. I agree with the comments of the above that there needs to be some flexibility for patient choice. The real answer is to give the patients a list of what is recommended and let them choose. If they think they aren’t getting what they need from their current doctor, then they should be allowed to find one that can. If they don’t want something done, then it’s between them and their health plan.

I don’t think lists are necessarily a bad thing however. Medicine has gotten so complex that reminders are needed. There is a very good reason that pilots have a check list before take off. It’s not because they are stupid, it’s because they have a lot to remember and verify, otherwise things get missed and people die. The same things happen in medicine. Expecting your doctor to remember 100% of everything that a particular person may need is not reasonable. Reminder lists do help to improve care and prevent medical errors.

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