Nice post. I have also opined in my own specialty journals about the fallacy of P4P and Medical Quality measurement. Of course, you are correct. Although the term ‘guidelines’ suggests flexibility, they take on the force of mandates in the real world. They can become handcuffs and shackles, not guideposts to educate us. In addition, they are usually designed by academic physicians and teaching institutions, who may have an agenda unrelated to true medical quality. For example, their guidelines for maintaining competency in lucrative medical procedures may ‘recommend’ very high case numbers, well beyond the reach of community physicians. They claim, of course, that this is solely to protect patients, but I wonder. http://www.MDWhistleblower.blogspot.com

1. Guidelines that are as perfect as possible: free from conflicts of interest in their conceptions, and taking into account all necessary clinical nuances (and by extension, having clear limits on their application to patient groups for which data are limited)

2. Guidelines developed under cost constraints: these will be imperfect, of course.

3. No guidelines. Wild West! (and we’ll never know just how wild it is, because we’ll have nothing to measure).

Things are probably only going to get worse re: P4P and protocol driven care. The only way to slow the train is for the reasonable skeptics to keep the heat on and continue to point out the significant limitations of such an approach to medical care.