Arguing for P4P


Category : Medical Rants

I have previously linked to retired doc’s thoughts on P4P and two recent articles. I finally have the time to carefully read the articles this morning. I started with Elliott Fisher’s article in the NEJM (free access) – Paying for Performance — Risks and Recommendations

I know Elliott through SGIM. He is a bright physician who has done remarkable research. He is thoughtful. But he has me totally confused. As a member of the IOM panel which recently recommended that CMS proceed with P4P, he writes these paragraphs.

Unfortunately, much of the current work in performance measurement and pay for performance seems to ignore one or more of the commonsense principles outlined by the IOM committee. The technical quality measures still reflect a tiny segment of clinical practice. The efficiency measures used or under discussion target discrete diagnoses and episodes (which can make fragmented care by multiple providers appear “efficient”), rather than the longitudinal costs and outcomes of care (which would reward comprehensive, coordinated care by single providers). Much of the focus appears to remain on the measurement of individual performance of physicians — a daunting technical and administrative challenge if implemented nationally. And little attention is being devoted to designing or building a comprehensive evaluation framework that would allow us to learn from our inevitable mistakes.

The shift from autonomy to accountability and from fee-for-service practice to new methods of payment appears inevitable. Accountability for performance on the basis of evidence is now the watchword for clinical services. We would be wise to apply a similar standard to the implementation of our health policy reforms.

As I read the entire article, he makes a strong case against P4P, yet he finishes with support of this scheme. I cannot really understand the logic in this article.

The Annals of Internal Medicine features an article which is also confusing. Pay-for-Performance and Accountability: Related Themes in Improving Health Care.

Is pay-for-performance here to stay or is it, as some believe, a passing fad, soon to be replaced by the next big idea? Only time will tell, but for now it seems to be a useful strategy to pursue. Some skeptics fear that pay-for-performance standards will morph into the ultimate “clinical cookbook” that restricts clinical judgment as the recipes improve. I think that this outcome is unlikely. Although access to almost real-time evaluations of clinical performance should reduce undesirable variability across physicians and hospitals, doctors will probably still vary substantially in their practice patterns. Hospitals will continue to vary so much that hardly two are alike. Although evidence-based standards are important, they are only a small part of the practice of medicine. Very good performance against measures of quality of care will become a necessary but not sufficient condition for success in clinical practice. It is hoped that the payment system will learn to reward the personal qualities that patients continue to seek in their physicians.

My father has always told me that if you can not explain something, you really do not understand it. As I read these two articles, I fear that the authors really do not understand what P4P implementation really means. Both articles are very confusing to me.

I get the sense that they are trying to justify an idea which is popular with politicians and insurance company executives. However, their justifications are essentially incomprehensible.

We have a responsibility to avoid a system which could potentially have negative effects. We should work to improve those measures of quality that we can measure, but we must recognize that some attributes of quality are probably unmeasurable.

I will continue to rant on this subject. For you see, “the emperor has no clothes”.

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Comments (12)

P4P = bribery

How is it any different or better than applying some index to a clinical activity in the manner of a “result” which can be scored and then used to index a payment for services (or a “bonus” to be first withheld, then bestowed, depending on “performance”)?

Unless there is a way to qualify the result to the initial clinical problem, the system will favor those practitioners who fix simple problems and disfavor those who must deal with difficult problems. Doctors with a patient population skewed to poor, obese, diabetics with poor glycemic control and significant comorbidities will have theirr work cut out for them if their metric is compared to others with a better–less complicated and comorbid– balance of patient problems.

A stick painted orange is not a carrot.

I see the problem. P4P in some fashion is going to be forced upon us by government and other payors. Every physician knows that this is a simplistic, absurd, and destructive scheme, yet we don’t want to appear as complete obstructionists. Maybe if we play along like we’re on the “team” we can soften the final product somewhat. I think we would be better off taking a firm stand against the P4P process by clearly pointing out why it will not accomplish its goals and why the gamesmanship that will inevitably accompany P4P will likely further reduce the quality of medical care in this country.

Note that the second article you discuss above was written by Dr John W Rowe, the immediate past-CEO, major stock-holder, and current board chairman of Aetna Inc. Clearly, it may be in the interest of Aetna Inc., a large commercial managed care organization, to promote P4P.
It is too bad that the Annals did not make Dr Rowe’s links to Aetna explicit in his article, which seems to amount to an exposition of Aetna’s position on the issue.
Another question is why the Annals gave Dr Rowe the opportunity to argue his company’s case without providing for an opposing point of view.
See this post:
in Health Care Renewal,

The problem with P4P is that the folks controlling the first P (pay) have no incentive to truly understand the second P (performance) as long as they can define it in a way that translates to more revenue, less cost for them. Since no one else can define that second P, the consumer and the provider will ultimately lose.

data mining:

“Medicare investigators in Los Angeles, using sophisticated computer technology to sift through claims data, saw an unusual pattern: A single patient had apparently undergone a diagnostic rectal-probe procedure 118 times in a year — at 21 medical facilities….”
(read on:

The 80s are over folks! Back then it seems that providers were very happy with how the second P was defined, by those other mean folks. (Whats the matter, trouble in paradisimo?)

No sympathy from this corner. Looks like the free market strikes back (second P redefined).

Whatever the guise, P4P can help prevent fraud, and thats important (for our children)! Now, just got to figure out a way to free the first P…

(but wait, why do i have to even think about freeing the first P. In an open market, denouced feudal society, in the 21st c, wth genomics, with healthIT… shouldnt this already be taken care of?)

the undoing?:,,1945029,00.html
If he can do it, can i, can i… ?
(insert uninsured, underinsured, dispossessed, disenfranchised in queue OR just insert normal people wanting to make a buck and are ready to fill a gaping market need)

diy diagnostic health test sales are up.
I wonder if i can bill for that? (oops, forgot u have to be part of the oligarchy to do that…)

hmmm, maybe thats part of the problem with health delivery. But i wouldnt know, I didnt pay 100K+ to be allowed to get certified to bill.

oh another idea:
open up the certification process. lets say we let the free market find some people who would study real hard, pass the same or more rigorous state-certified test, and work happily for +/-80K…

I wonder how many people she (the market) could lure- that could pass the state test. If she found enough the work schedules and patient loads would be much smaller, these people could even use google or other resources. I wonder how many providers would have to rise to the incentives of the market that would bring about a mean doc salary of 80K (minus the whining about P4P pay schedules)?

wow, those sure are weird questions- maybe ill find the answer some day
(shame on us for not already have. its called freedom- of the markets, of information, of people. its a beautiful thing, and we enjoy it in a variety of forms everyday)

enjoy more!

“oh another idea:
open up the certification process. lets say we let the free market find some people who would study real hard, pass the same or more rigorous state-certified test, and work happily for +/-80K… ”
Passing a written test is different from having the ability to practice good medicine. Many bright internal medicine residents are capable of passing the internal medicine certifying exam after their internship year, but that doesn’t mean that they have the same skills as someone who has completed a 3-year internal medicine residency. The psychiatry written board exam is very easy and can be passed by someone with only a few months of training in psychiatry (the psychiatry oral exam is anothe story).

please… please….
somebody save the children, somebody save my baby, please…
please, i surrender my rights, my dignity, we’ll allow a feudal priest class to diagnose and prescribe…

Hospital errors are in the top 10 ways to meet the reaper… so much for indentured servitude, cartel enforced residency training program!

please save the children.
(insert bagpipers)

new study: “About 20% of all diseases are misdiagnosed, a percentage that has remained steady since the 1930s. However, scientists have discovered that by inputting the key symptoms into Google they can get the correct diagnosis about 58% of the time. For rare and unusual diseases, this provides doctors the information they need to get a correct cure. Of course, Google is only as good as its knowledge base, and its users, so this isn’t a cure for everything.”
(but were getting there… of course w/o the help of those who argue nuances of P4P vs HMO vs blah blah vs BS… again, its simple artificial scarcity. Artificial scarcity of who is allowed to sell information (medical) wrapped in a save the children for ur rights argument.”

(as always)
ur options/rights:

go overseas: retain your dignity, do not become a charity case (the cartel loves to

market how charitable they are when it comes to rent collection)


walmart is rolling out $40 visits, i heard costco is thinking about this also(?)

credentialing (free-market style):

search engines:
google health

-be careful out there

Get google health to remove your inflamed appendix , dipshit – here’s a helpful hint- try and do your bit to prevent medicare fraud.

definitely internet access helps, I use some excellent on line sources @ 5 times/day. the medical library I use has extensive information on virtually every known disease. The only problem I have is the time issue….an google internet search can take quite a long time to sort through the hits, while a more organized medical database saves time. Any physician who does not have computer or electronic databases is either brilaint or out of date.

also I would note that being a priest is not even comparable to being a physician. The priest takes vows of poverty and chastity …the physician takes no such vows.

Important health tips which can keep us motivated to live a healthier life. An unhealthy lifestyle can be the reason for many diseases like diabetes, heart diseases, hypertension, etc. Hence to keep yourself away from these diseases there are two solutions. One is following a healthy lifestyle & the second one is a preventive health checkup.


Dr Abhishek Mishra is an experienced orthopaedic surgeon in Delhi for joint replacement surgeries such as hip and knee replacement and arthroscopy surgery as well. You can meet Dr Abhishek Mishra at VNA hospital, Malviya Nagar, Delhi.

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