Comments on: P4P – some data

By: Dr. Bob

Dr. Bob — Fri, 14 Oct 2005 14:34:42 +0000

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.

By: Steve Lucas

Steve Lucas — Wed, 12 Oct 2005 19:00:53 +0000

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.

By: Diora

Diora — Wed, 12 Oct 2005 17:32:00 +0000

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.