Improved performance – P4P or consistent primary care?

7 Feb
2010

The best way to lower health care costs and improve outcomes is to spend more on excellent primary care.  The data are consistent, and the concept has great face validity.

This article is intriguing – For Diabetes, P4P Improves Patient Care, Outcomes

As one reads the article, skepticism about the title enters.

High-quality care — defined as receiving at least two tests for glycated hemoglobin (HbA1c) and one for LDL cholesterol during a given year — was delivered 16% more often by physicians in the pay-for-performance system (rate ratio 1.16, 95% CI 1.11 to 1.22), the researchers also reported online in the American Journal of Managed Care.

"This study showed a robust, consistent, significant, and positive association between increased receipt of appropriate laboratory monitoring of A1c and LDL cholesterol levels and decreased hospitalization rates," Chen and colleagues declared.

On the other hand, the researchers also found that quality of care diminished when patients saw multiple primary care physicians during a given year.

"This finding supports the hypothesis that patients have better outcomes when they have a medical home," Chen and colleagues indicated.

The problem with these studies is the problem of multiple confounders. At least the performance measures used here were ones that we can endorse as not being overly directive – they did not specific the goals of treatment, only the measurement.

What I find more important in this article is that admissions decrease with primary care consistency.  This is the big point that Congress does not understand.  This is the big point that the CBO will always refuse to use in their calculations.

The best way to lower health care costs and improve outcomes is to spend more on excellent primary care.  The data are consistent, and the concept has great face validity.

Subspecialists argue this point, because they are protecting their turf.  They are no disingenuous, rather they see the world through subspecialty eyes, focusing on their diseases.  Consistent primary care more often focuses on the patient than the diseases.  Excellent primary care physicians treat the diseases in the context of the other diseases and the patient's desires. 

We can only improve care if we invest in better primary care.  That will require making the job a better one – less patients per day. less administrative hassles and (I believe) a salary rather than fee for service billing.

Related posts:

  1. Must read article on primary care
  2. Performance indicators need testing
  3. Why health care reform should focus on primary care
  4. Guidelines and performance measures need testing
  5. My position on performance measures

Related posts brought to you by Yet Another Related Posts Plugin.

Comment Form