In which the NY Times publishes an anti-P4P article

by rcentor on September 9, 2008

The Pitfalls of Linking Doctors’ Pay to Performance

The program is called pay for performance, P4P for short. Employers and insurers, including Medicare, have started about 100 such initiatives across the country. The general intent is to reward doctors for providing better care.

For example, doctors receive bonuses if they prescribe ACE inhibitor drugs to patients with congestive heart failure. Hospitals get bonuses if they administer antibiotics to pneumonia patients in a timely manner.

On the surface, this seems like a good idea: reward doctors and hospitals for quality, not just quantity. But even as it gains momentum, the initiative may be having untoward consequences.

To get an inkling of the potential problems, one simply has to look at another quality-improvement program: surgical report cards. In the early 1990s, report cards were issued on surgeons performing coronary bypasses. The idea was to improve the quality of cardiac surgery by pointing out deficiencies in hospitals and surgeons; those who did not measure up would be forced to improve.

But studies showed a very different result. A 2003 report by researchers at Northwestern and Stanford demonstrated there was a significant amount of “cherry-picking” of patients in states with mandatory report cards. In a survey in New York State, 63 percent of cardiac surgeons acknowledged that because of report cards, they were accepting only relatively healthy patients for heart bypass surgery. Fifty-nine percent of cardiologists said it had become harder to find a surgeon to operate on their most severely ill patients.

Whenever you try to legislate professional behavior, there are bound to be unintended consequences. With surgical report cards, surgeons’ numbers improved not only because of better performance but also because dying patients were not getting the operations they needed. Pay for performance is likely to have similar repercussions.

Consider the requirement from Medicare that antibiotics be administered to a pneumonia patient within six hours of arriving at the hospital. The trouble is that doctors often cannot diagnose pneumonia that quickly. You have to talk to and examine a patient and wait for blood tests, chest X-rays and so on.

Under P4P, there is pressure to treat even when the diagnosis isn’t firm, as was the case with my patient with heart failure. So more and more antibiotics are being used in emergency rooms today, despite all-too-evident dangers like antibiotic-resistant bacteria and antibiotic-associated infections.

I recently spoke with Dr. Charles Stimler, a senior health care quality consultant, about this problem. “We’re in a difficult situation,” he said. “We’re introducing these things without thinking, without looking at the consequences. Doctors who wrote care guidelines never expected them to become performance measures.”

Readers of this blog actually are familiar with these concepts, but you probably share my pleasure with these concepts receiving wider exposure in the newspaper of record. I highly recommend this well written article.