Comments on P4P from the SGIM national meeting

The Puzzle of Quality: Clinical, Educational and Research Solutions was the official theme of the SGIM national meeting. The ACP observer reports this month on some highlights of the meeting – Doctors debate P4P, address impact on primary care

The following quotes are worth considering:

“I fear that we as primary care providers have boxed ourselves into a corner,” said Nicole Lurie, MACP, former SGIM president and current director of the RAND Center for Population Health and Health Disparities, during the April meeting’s keynote address. “We are doing a better job following the guidelines and checking the boxes,” as reflected in the improvements in standardizing processes of care as gauged by the first batches of quality measurements, “but outcomes are not improving.”

and

In the United Kingdom, for instance, researchers found that the national P4P program introduced in 2004 motivated general practitioners to improve care by making better use of previously underused information technology and multidisciplinary teams. Bruce Guthrie, MB BChir, PhD, of the University of Dundee, in Dundee, Scotland, who presented a study on the U.K. program, said general practitioners worried about two negative consequences of P4P:

Tunnel vision: Concentrating on the conditions eligible for incentives means less time for patients with conditions that were not being measured by the program, such as depression.

Crowding out: Reducing or eliminating primary care services without specific reimbursement, such as travel medicine.

and from the debate:

“How much can a doctor improve by doing what you want and how much by doing what you don’t want them to do?” Dr. Hayward asked. “It’s easier to improve my score by getting rid of one to three high-cost patients than by changing my practice for all. Deselecting high-cost patients is easier than improving care.”

Moreover, he said, variation noted among individual physicians is due more to patient and chance variability than to physician variability, he said. “We have been saying [quality] is a systems issue, but now we’re saying, we have to look at the individual doctor.” It’s like judging the quality of a product produced at one factory by the individual assembly line worker and not by the factory as a whole, he said.

===========

In Dr. Hayward’s opinion, however, these new measures are just as flawed as the old ones—and maybe even worse, because they are bad measures of quality. For instance, there is no good evidence that all hemoglobin A1c levels must be below 7%. And, he said, concerning blood pressure measures, pushing patients to reduce blood pressure from 140 mm Hg to 130 mm Hg can do more harm than good for some patients.

“You can’t have simplistic measures and think you are measuring quality,” Dr. Hayward said. “The measures don’t reflect the reality that you have to tailor treatments to individual patients.”

Never forget with HL Mencken said (scroll down and view the quotes in the right hand column).