I look forward to reading Dr Rich’s book. This rant (Pay for Performance and Covert Rationing) expresses many thoughts that I have previously expressed concerning P4P. I especially like this paragraph.
P4P also relies on the Axiom of Industry – that the standardization of any process both improves quality and reduces cost. As DrRich has described elsewhere, the Axiom of Industry does not hold when the process involves actual human patients. This is because patients are not widgets. (While everyone agrees that patients are not widgets, the implication of this fact seems to have escaped many: What happens to the individual widget on an assembly line is immaterial – discarding even a high percentage of proto-widgets may be fine – as long as the ones that come out the other end are of sufficiently high quality as to yield the optimal price point in the market. Patients not being widgets, in theory we are supposed to care about what happens to the individual patient during the process.) Nonetheless, invoking the Axiom of Industry – equating reduced cost to improved quality – allows the central authorities to choose “quality measures†in their P4P efforts that will primarily reduce cost, and then to claim that their primary concern is for quality.
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