Why P4P can hurt patient care


Category : Medical Rants

For years I have railed against P4P.  The concept seems so right to the wonks and politicians. The concept seems right if you have shallow thinking.  If you ask practicing physicians to do a pre-mortem analysis on how P4P would fail, they would have understood.

Last week in my favorite thought provoking blog (Farnam Street), they published a wonderful piece that explains the problem well – The Distorting Power of Incentives.  While I hope you read that post, I will provide the essence.

Understanding incentives comes through second-and-third-level thinking. Many incentive systems have backfired because people failed to consider other interests and incentives.

P4P rewards physicians or systems for meeting certain measurements.  First level thinking involves identifying a guideline, learning that adherence to that guideline varies, and then providing rewards for certain percentage of adherence.  Second and third level thinking looks at the entirety of patient care.  It asks whether shining the light on a set of measures might detract from other aspects of patient care.

Good incentives acknowledge recognition, public perception, and the value of pursuing work that we can be proud of. So yes, if we want to persuade, we should appeal to interests not reason. But when it comes to interests, appeal not just to net worth but also to self-worth.

While money has great importance, most physicians value more than money.  We want to do what is best for the patient.  We have our own concepts of what a good physician does for their patients.

We know that P4P plans have some influence on the care patients receive.  Occasionally they improve targeted care, but they can detract from care that does not have a measurement.

P4P is the wrong idea.  It represents shallow thinking.  The concept ignores what we know about motivation.  It ignores what we know about the complexity of patient care.

It ignores an understanding of the impact of incentives.

Comments (11)

What’s the alternative then?

I’ll use stroke recovery as an example. Only 10% almost fully recover. If we don’t have some kind of result goal greater than that, how will patients be better served?

You hit the nail on its head.

A stroke patient and their medical care team are always aiming for the maximum possible improvement. Why would you deliberately not try to get the best outcome? The government setting a goal for improvement is not going to affect outcomes either way. We already are doing our best – soo The patient is not better served by setting some kind of arbitrary goal on paper.

If you get paid less and harassed more if your patients do not achieve a certain level of outcome, then the temptation is NOT to take on difficult patients that you know will be less likely to do well. The sickest people will find it harder to get care if the docs are penalized for taking them on.

Like most things that come from this government it’s a scam. The affordable care act is a tax and spend act that overall made healthcare less affordable unless you are in the bottom rungs and you don’t pay anything anyways.

P4P is not really a way to pay the doctor more for doing a better a job it’s really a way to find an excuse to pay the doctor less. Just look at the latest Medicare fee schedule. The prior schedules supposedly paid according to where the CPT was performed and the overhead cost involved. Now it’s based on whether you jumped through specific hoops while even if you get paid the full amount they are paying doctors less than 30cents on the dollar. If you correct for inflation and backtrack to fee schedules from 20+ years ago you can see why fee for service care cannot survive on Medicare. The current administration thinks every doctor should just be an employee but that has been proven to raise overall costs.

my favorite is when they inevitably raise the targets so they always can have a large chunk of doctors/practices who don’t meet the bonus, no matter how well they do.

As Aaron said, an ongoing adjustable excuse to pay less to most physicians

It’s time get off this hamster-wheel.

From a 45-year RN/ Prof Emerita:

This article broke the cardinal rule in good reporting or writing:

Define all acronyms as soon as they are used in text.

Seems obvious to me.

What IS P4P,Somebody?

Pay for performance = P4P

Regular readers and almost all physicians use the term P4P. On this blog I am not embarrassed to us acronyms.
As Judy B wrote – P4P is pay for performance.

Money is used to reward/punish since politicians and medicrats do not understand non-pecuniary motivations. The same people believe I prescribe certain meds only because I was given a logoed pen or notepad 10 years ago.

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