Pay-for-Performance in Endocrinology

With pay-for-performance looming, I am concerned about the impact this will have upon both specialists and their patients.

As specialists, endocrinologists are generally sent the more challenging patients, which is appropriate. Given the shortage of endocrinologists, primary care physicians really should be taking care of most uncomplicated patients with type 2 diabetes. I actually discourage our referring physicians from sending us patients who are well controlled on oral agents. 

Having said that, if we will be paid someday based on whether or not a patient’s HbA1c is at goal, we may be in trouble. If we are only seeing patients who have had diabetes for many years, those who have failed 2 or 3 oral agents, and those to whom their primary care physicians have just thrown up their hands, we will have (and do have) a significant number of patients whose HbA1c is above goal. 

Furthermore, guidelines change and insurance companies’ policies lag behind. For example, if you have a large elderly population, or see a lot of patients who already have multiple complications, their goal HbA1c is higher than that of the general population. Will the payors recognize that? Will they take into consideration that the risk of hypoglycemia outweighs the benefits of tight control in these patients, or will they just look at the numbers and say, “Mrs. Smith has a HbA1c of 7.2, which is above the recommended level of 7.0”? Right now, I get those ridiculous letters telling me that the patient isn’t on an ACE or ARB even though it is in her chart that she had a severe adverse reaction in the past, or that the patient isn’t on a statin even though she is only 21 years old and her LDL is 105. Are we going to need to justify a HbA1c of 7.2 every time so we can get paid appropriately? 

And none of this puts any onus on the patient. You can tell patients to get their labs done, to change their diet, to lose weight, to take their meds regularly, to see their eye doctor, but you can’t do that for them. So then what? Does the physician get punished financially because the patient refuses to take insulin? Or (and this concerns me) will some physicians stop seeing patients who mess up their statistics? Don’t say that can’t happen. I have heard of surgeons who will not operate on patients who are less likely to have good outcomes and will operate on some patients who may not have needed surgery but will probably do well after, because it makes their post-op statics look good. So what if endocrinologists start “sub-subspecializing” in thyroid disease only? 

I’m not saying that pay-for-performance isn’t good in theory. I do believe that those who provide better care should be paid more than those who don’t. My concern is the implementation. Who decides what the benchmarks are, how is the data collected and (more importantly) analyzed, what recourse will a physician have if he is “dinged,” and what is the patient’s role? These are important questions that need to be answered.