Forget P4P

One of the central approaches for quality improvement these days seems to be pay-for-performance (P4P), but its effectiveness doesn't seem to be there.

One of the central approaches for quality improvement these days seems to be pay-for-performance (P4P), but its effectiveness doesn’t seem to be there, according to a July/August, 2008 Health Affairs article. “Overall, P4P contracts were not associated with greater improvement in quality compared to a rising secular trend. Future research is required to determine whether changes to the magnitude, structure, or alignment of P4P incentives can lead to improved quality.” In other words, forget the current propaganda. Moreover, this is not to say that medical/surgical practices are not improving over time; only that P4P programs have little to do with that trend.

In fact, if you cull the article (the link can be found below in “References”), you’ll see the incentivized docs were a couple percentage points or more below the comparison group in terms of HEDIS measures-Breast, Cervical Cancer Screening, Chlamydia Screening, Eye Exams, HgbA1c and LDL-C testing in Diabetics and well-child (ages 3-6 or adolescents) in 2001 and 2003. As Greg Scandlen, founder of Consumers for Health Care Choices has said:

“Leaving aside the question about whether any of this measures anything meaningful - other than marking off boxes on a check list (notice there is nothing here about actually listening to your patient, or finding and treating anything that might be wrong, or persuading the patient to change behavior), what else does it show us?

It shows us that the much-vaunted pay-for-performance system is useless, not withstanding the fact that private payers, Medicare, and the presidential candidates all promise that such programs will save the health care system. In fact, on many measures the "non-incentivized" physicians improved more than those who were "highly incentivized." Golly, is it possible that physicians actually pay attention to the emerging literature and freely change their practices in the interests of good patient care? Oh, no, that can't be it.

Additional Resource

Jauhar, S. "The Pitfalls of Linking Doctors’ Pay to Performance." NY Times, Published: September 8, 2008.

P4P - Poor Care for Profit

Dr. Jauhar, a cardiologist on Long Island writes in the NY Times (September 8, 2008) about “The Pitfalls of Linking Doctors’ Pay to Performance,” [1] emphasis the word “to.” He introduces the issue of incentives that don’t incentivize by speaking to the all too familiar discovery on reading a colleagues chart, even with permission. In his piece, the sentinel event or scenario, a patient was getting daily antibiotic for no apparent reason, given the labs, x-rays, clinical course and diagnosis of congestive heart failure not caused by infection. And, if that wasn’t telling enough, the unnecessary treatment at “discovery” was already on its way to causing harm -- a severe diarrheal infection called colitis with dehydration, the proximate cause being C. difficile, which is often caused by antibiotics.

Dr. Jauhar correctly states that part of the blame lies with the unintended consequences of pay for performance or P4P programs. Designed to improve patient care, these initiatives may give doctors bonuses if they “prescribe ACE inhibitor drugs to patients with congestive heart failure. Hospitals get bonuses if they administer antibiotics to pneumonia patients in a timely manner.” Surgical report cards were another example. Meant to improve the quality of care, in this case, of coronary bypass surgery, they lead to “cherry-picking” patients. And “In a survey in New York State, 63% of cardiac surgeons acknowledged that because of report cards, they were accepting only relatively healthy patients for heart bypass surgery. Fifty-nine percent of cardiologists said it had become harder to find a surgeon to operate on their most severely ill patients.”

Consider the chilling effect of misaligned incentives - avoiding the sick, patient referral (dumping), over treatment, rewarding the status quo, “benefiting mainly those physicians who already meet the guidelines,” etc.