Don't Mess Up Primary Care Reimbursement Incentives

Patients' clinical characteristics and demographics have a significant effect on pay for performance outcomes.

In “Relationship Between Patient Panel Characteristics and Primary Care Physician Clinical Performance Rankings,” a study published in the September, 2010 issue of The Journal of the American Medical Association, researchers have confirmed that the patient panel that doctors care for can have just as much of an influence on pay-for-performance (P4P) rankings as the doctors’ clinical decisions.

In the study, practitioners who took care of older or sicker patients tended to rank higher on P4P, presumably because these patients required more intense, obligatory, and frequent follow-up care, while primary care practitioners who cared for minority, non-English-speaking, and/or underinsured patients tended to have lower quality rankings than their counterparts.

Commenting on the JAMA study in a recent New York Times column, “Paying Doctors for Patient Performance,” Pauline Chen, MD, noted that when the researchers analyzed the data and “attempted to rerank all the doctors after adjusting for differences in patient characteristics” by factoring “patient race, ethnicity, primary language and insurance status into their physician evaluations,” they found that many of the original rankings changed. Doctors who worked in community centers (and “therefore with more minority and non-English-speaking patients”) were “more likely to improve in ranking, often by more than 10 percentile points.”

Incentive realignment in a nutshell

Fee-for-service (FFS) medicine may be associated with cost-ineffectiveness, if not cost-inefficiency, because the incentive there is to over-do care. Prospective payment is the obverse -- problematic in a different direction — because the incentive there may be to do less and that may mean less than optimal care. However, there is hope in adopting evidence-based clinical decision making. But beware the autonomous doctor -- he or she will call this third option “cookbook” or governmental medicine. See Parekh and Barton, “The Challenge of Multiple Comorbidity for the US Health Care System,” in JAMA for more on this.

For poignant, contemporary examples of comparative effectiveness research see “Failing Complicated Care, What's Next?