P4P discriminates against physicians who do not discriminate

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Category : Medical Rants

More Evidence That Pay For Performance Is Working

DrRich with his expected wisdom and sarcasm tells a wonderful story about the impact of P4P:

This week, at Digestive Disease Week (the year’s major scientific gathering of gastroenterologists), doctors from Johns Hopkins will present a paper demonstrating that pay-for-performance reimbursement schemes create financial incentives for surgeons to shun obese patients.

Under this species of pay-for-performance, surgeons are “rewarded” (i.e., not punished) for meeting specified quality standards which have to do with certain patient outcomes. (For pay-for-performance to occasionally equate quality with outcomes is a particularly useful formulation, since expressing reservations about such pay-for-performance measures immediately brands one as being against good medical outcomes, in the same way that being concerned about illegal immigration brands one as being against immigrants, or having reservations about certain of President Obama’s policies brands one as being a racist.)

The Johns Hopkins researchers have found that performing surgical procedures on obese patients results in substantially more complications than performing the same surgical procedures on non-obese patients. For instance, fat people had 27% more complications after gall bladder surgery, and 11% more complications after appendectomy, than thinner people. They also had substantially longer hospital stays, and generated much larger medical bills. The researchers conclude that surgeons (some of whom are literate and understand rudimentary statistics, and therefore not only have access to this kind of information, but are also capable of processing it to at least some extent) can only conclude that, in order to maintain a viable surgical practice, they will need to avoid operating on obese patients. At the very least, they will need to avoid doing elective surgery on fat people, waiting instead until they are in extremis, and require emergency surgery (since at least some effort is made to “adjust” the expected outcomes in these situations).

This result, of course, is similar to the result DrRich reported regarding the publication of Physician Report Cards. Namely, thanks to publicly-available report cards, cardiologists in the state of New York have been more reluctant than cardiologists in other states to aggressively treat patients with severe heart attacks, and as a result (while the report cards are cleaner) the mortality of these patients is higher in New York.

Thus, P4P makes it more difficult for more complex patients to have surgery.  The paradox tells us that P4P then discriminates against physicians who do not discriminate!  As a physician we should care for the patients who present to us and provide the best care for that patient.  P4P can encourage us to "cherry pick".  Adopting DrRich's logic, should we not declare P4P discriminatory and therefore illegal. 

And oh, by the way, P4P in other fields leads to cheating – Study: Employees More Likely to Cheat with Bonus-Based Incentives Programs

Comments (5)

I’ve tried to do my part in speaking out (writing out) against pay-for-paperwork, which will become another opportunity for gaming the system in order to capture a few extra coins of reiumbursment. I think it has more chance of lowering medical quality than increasing it.

P4P discourages doctors from caring for the sickest patients who need the most help. (and “risk adjusting” is simply inadequate.)

Sounds unethical to me.

I hope someone, somewhere, is listening.

Currently a few Medicare HMOs exist with special contracting with capitation. If you are an efficient doctor with low utilization, you get a 10% bonus at the end of the year by selecting only the healthiest patients. If you have the sickest patients and overutilize the system, you are dinged 10% at the end of the year. In this system, the wealthiest docs takes care of the healthiest patients.

This is a typical example of why P4P does not work. I heard a politician on TV sunday saying that we have to pay 4 performance giving the example that his father after bypass had an infection (staph he said) and that is is not good performance. The problem is who decides the good or bad performance. If it is the government and politicians doctors loose. The politicians needs to listen and quote the example that you give in this case.

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