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    Monday, November 30, 2009

    Section III of III The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans

    Section III of III The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans

    MY OPINION:
    The idea of paying physicians more for providing guideline-based care has taken the American health system by storm in the last decade. Today, more than 150 pay-for-performance programs are centered on the notion that rewarding evidence-based care is key to improving health care quality.

    Does evidence based research show that P4P is efficacious and improves quality care? No. At least not yet.

    Some P4P efforts have shown beneficial results, according to the Centers for Medicare & Medicaid Services. An evaluation of its Physician Group Practice Demonstration found that all 10 participating practices hit or exceeded targets on at least seven of 10 quality metrics of diabetes care. A Feb. 1, 2007, New England Journal of Medicine study found that Medicare's pay-for-performance demonstration project was associated with a modest improvement on quality metrics, compared with hospitals not in the project.

    Steven D. Pearson, MD, president of Harvard Medical School's Institute for Clinical and Economic Review says that "Unless you look at a control group of some kind, you may be misled about what's really happening."

    There appears to be a fundamental problem with current P4P programs. They have had little to no impact on quality. That is the conclusion of many studies, including an analysis of quality incentives, published in the July/August, 2008 of Health Affairs. It compared 81 Massachusetts physician groups eligible for quality incentives with 73 that were not. The study did find, however, that overall performance from 2001 to 2003 improved on 73% of preventive care measures such as diabetes hemoglobin A1c testing, breast cancer screening and well-child visits. But the performance of the 5,350 physicians analyzed was statistically indistinguishable. Everyone's quality improved, regardless of whether the physician group stood to earn a bonus, which ranged from $200 to $2,500 per quality measure for an individual physician, depending on the health plan.

    Another study that examined the CMS hospital P4P data also wasn't positive about P4P. A June 6, 2007, Journal of the American Medical Association study of heart attack care found no significant improvement for 54 hospitals in the CMS P4P demonstration, compared with 446 nonparticipating hospitals.

    And a systematic review of 17 studies, published in the Aug. 15, 2006, Annals of Internal Medicine, found positive or partially positive effects of P4P programs, but the impact was usually small.

    We actually have remarkably few evaluations that have a comparison group of any kind, so the evidence on pay-for-performance is rather spotty.
    Overall the P4P programs evaluated over the last five years have been largely unimpressive in their results.

    Please remember, as with all our articles we provide information, not medical advice.
    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

    *Tune in later for Acid reflux foods.

    Deepen your understanding of "medical malpractice"... www.MedMalBook.com

    For more health info and links visit the author's web site www.hookman.com

    Monday, November 23, 2009

    Section II of III. The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans

    1. From Woolf, SH, JAMA, Vol. 282, 1999 - Estimated savings for good treatment of DM, HTN, MI, Colorectal CA, Pneumonia over current treatment levels.
    a. DM control could prevent 2,600 cases of blindness and 29,000 cases of kidney failure.
    b. HTN control could prevent 68,000 deaths
    c. Following evidence guidelines in MI could prevent 37,000 deaths
    d. Administration of pneumoccal vaccine could prevent an estimated 10,000 deaths per year
    e. Colorectal cancer screening could prevent an estimated 9,600 deaths per year (not to mention the cases where multiple hospitalizations and chemotherapy are needed.)

    2. From Diabetes Care - Vol 20, Number 12, Dec 1997 - Cost of diabetic with A1c at 6-7% is $378/year, with A1c of 9-10% is $1205 per year. Cost of Diabetic with CAD and HTN is $1505/year at A1c of 6-7%, $4116/year at a1c of 9-10%

    3. Premier Report came out last month: Simple adherence to basic medical treatment guidelines for Medicare patients hospitalized for CABG, MI, and Knee replacement would save $1.35 billion per year. 5,700 deaths, 8,100 complications and 10,000 readmission to the hospital could be averted if clinicians followed medically prescribed treatment steps.

    4. Bridges to Excellence (Bridgestoexcellence.org) has found that for every $1 bonused to a primary care doctor, there was a savings of $3 to the payor (not insurance company in this case, but employer). BTE is an initiative initally by fortune 500 companies and was outside of insurance companies.

    Doctors say:
    The doctors respond with their argument is not that P4P is the solution to all problems. Instead, the main focus now should be on the current reimbursement system that does not simply not pay for good care, but it encourages bad care.
    The recent study that showed that over half of elderly patients leave the doctor's office without proper medication advice is a good example. Why is this? It happens because doctors are pressured to see as many patients as possible to meet overhead and consequently spend less time on each patient. Medicare cuts should only add fuel to this fire.

    There’s plenty of data that shows that medical care in the US is not nearly at the quality it should be. It is not the doctors that are at fault (in their opinion) but the system that does not reward good care, but instead rewards doctors who spend as little time as possible with patients.

    Doctors say:
    The doctor’s main point, is that the current payment system is broken, CMS is dead set on fixing it via P4P.
    But say the doctors instead of being judged for whether a test was done (without EMR, this is the only way to measure performance, as it is based on claims data), but whether it was addressed by the physician.
    If a patient chooses to not have a mammogram, the doctor should be able to report that they refused it and get credit for addressing the issue.
    If blood pressure is up and the doctor responds appropriately, he/she should be credited for doing the right thing, regardless of the outcome.
    The concept should be that measuring physician behaviors on an EMR system so as to accurately record the intent of the physician.

    Please remember, as with all our articles we provide information, not medical advice.
    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.


    *Tune in later for Section III of III. The Debate.

    Deepen your understanding of "medical malpractice"... www.MedMalBook.com

    For more health info and links visit the author's web site www.hookman.com

    Monday, November 16, 2009

    Section I of III. The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans

    Doctors say:
    "Pay for Performance" (often abbreviated P4P) is based on the false concept that doctors will take better care of patients if they're paid more.
    Big insurers in each state; are discussing P4P as the next thing as they ratchet down reimbursements and pile on the denial hassles according to practicing physicians.
    Why P4P?
    Is it to save more money for medical insurance carriers.
    Or is it truly to reward better quality medical care?

    Capitation is broken say doctors.
    Capitation is/was a way to shift the risk of having to pay for a doctor's visit away from the insurance company and onto the doctor. Somehow or another back in the early '80s enough people were fooled, but have since wised up say doctors. If no one's willing to take it on, capitation won't work. That's why it's fading away, say doctors.

    Fee for service is broken say the insurance carriers.
    Baloney- say the doctors. “Pay me a reasonable rate for what I do and I'll be happy as a clam.”

    Insurance carriers say:
    • Fee for service has no incentive for quality
    • Thus we need Fee for service + bonus/incentive to reward quality
    Doctors say:
    At no point in P4P discussions has the word "Quality" ever effectively been defined in the context of medical care.

    Insurance carriers say:
    What percentage of your diabetic patients have A1C's under 7%; how many of your hypertensives' blood pressures are controlled?
    What % of patients had mammograms and colonoscopies?
    That’s what tells us that your patients are getting food or bad quality care.

    Doctors say:
    The central element of "quality" will forever remain fundamentally un-measureable; and here's why:

    In the primary care context, the essence of a given encounter for medical care consists of an interaction between two people: the doctor and the patient. There are certain things doctors expected to do: ask appropriate question to elicit sufficient information to come to an accurate diagnosis; decide upon and discuss various treatment options with the patient; make sure that the patient has enough information, education and emotional support to understand and implement the treatment (or work up) plan; and so on.
    But the key element is that the encounter is an interaction. There are two of us. The quality of that interaction is not 100% dependent on me. Any attempt to "measure" it implies that it is. And doctors don't buy it.

    The discussions on P4P inevitably turns to EMRs (electronic medical records) as an integral part of P4P. Everyone has to have them; that's how they're going to get the performance data they're going to pay doctors.
    But once all the numbers are crunched, though, it turns out a doctor will see only about $3,000 in P4P bonuses for a $30,000 EMR investment..
    The response by insurance carriers is that the real return is more likely to be in the areas of quality and lifestyle.
    Doctors reply:
    Imagine presenting a proposal to an insurance company -- actually to any kind of business -- and saying, "Now, you'll only make back about 10% of your initial investment, but you're likely to see improvement the areas of quality and lifestyle."

    Doctors see P4P as in the early 1990’s when the buzzword was "vertical integration." Hospitals and health systems were buying up medical practices. The idea was that by consolidating the referral base, the "system" would rake in the profits, which would then trickle down to the now employed physicians. The private office, especially solo, was considered an unworkable business model. Over the next ten years, it didn't work out quite the way the hospitals and health systems said it would. So docs were stuck either buying back their own practices, or being subjected to more and more outrageous working conditions (required to see 56 patients in 8 hours, etc.)

    Doctors say:
    This whole "pay for performance" thing doesn't sound quite right for many reasons. They believe that when everyone seems to think something is so, but can't explain it in a way that it makes sense to them, there's something wrong with what they're saying.

    And what is quality they ask?
    Openly discussing both benefits and risks of screening or just using scare tactic to get more patients screened?
    If you are not mentioning the risks, if you using relative mortality reduction and not mentioning the real chance of your patient benefitting, are you not misleading the patient?
    It happens already, but at least now, the doctors respect the right to choose.

    Doctors say:
    With P4P doctors will be loosing money for every patient with LDL 4 points above guidelines (even those with 10-year heart attack risk of 1%). A 40-something ballet teacher with no family history of heart disease and normal ratio, albeit slightly elevated LDL is complaining of muscle side effects that interfere with her ability to do her job (saw this woman's post on one of the forums) - "what would you rather have: a heart attack or muscle pain?"

    No explanation of the actual magnitude of benefit for her; after all if you mention that you are only talking about 0.3 percentage points in ARR, a patient might refuse and here goes you P4P. "It'll reduce your heart attack risk by whopping 30%".

    Very few patients would think to ask "n% of what number exactly?"
    Incidentally, maybe P4P should also evaluate physicians on providing honest and accurate information (to the best of the existing evidence) to the patients and respecting their right of informed refusal?

    Anybody thought of making this one of the criteria?
    Whether or not it is cost effective depends on absolute risk reduction for a particular person. For diabetics or people who already had heart disease it may well be (although if someone doesn't take drugs and dies sooner, will this person save money or use more of it?)
    But when you are talking about measures with small absolute benefit, it should be individual choice.
    As a patient I have a right to decide for myself whether certain small risk reduction worth the risks or side effects for me or not.
    I don't want an incentive for a doctor that would depend on the choices I have a right to make.
    I want an incentive to provide accurate information but without the vested interest in my decision.


    Please remember, as with all our articles we provide information, not medical advice.
    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.


    *Tune in later for Section II of III. The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans.

    Deepen your understanding of "medical malpractice"... www.MedMalBook.com

    For more health info and links visit the author's web site www.hookman.com

    Monday, November 9, 2009

    Survey suggests more than two-thirds of Americans may be overweight or obese.

    Vital Statistics reports that, according to a "nationwide survey of obesity" based "on data for 2005 through 2009 gathered by state health departments with the help of the" CDC, "more than two-thirds of Americans are now overweight or obese, and the percentage is still rising." The study, which was "published by the Robert Wood Johnson Foundation and the Trust for America's Health," defined "overweight as a body mass index (BMI) of 25 to 30, and obesity as a BMI over 30." Specifically, "compared with 2008, obesity rates rose in almost half the states, and decreased in none." Notably, in Alabama, Mississippi, Tennessee, and West Virginia, "more than 30 percent of adults are obese," and "eight of the 10 states with the highest obesity rates are in the South." The study also revealed that "in 30 states, 30 percent or more of children ages 10 to 17 were overweight or obese." In 1991, no state had an obesity rate above 20 percent, and in 1981 the national average was 15 percent."

    Please remember, as with all our articles we provide information, not medical advice.
    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

    *Tune in later for Section I of III. The Debate between Doctors and Insurance carriers about “pay for performance” [P4P] reimbursement plans.

    Deepen your understanding of "medical malpractice"... www.MedMalBook.com

    For more health info and links visit the author's web site www.hookman.com

    Monday, November 2, 2009

    Stroke, tPA & Statistical Chance

    Knowledge should accompany any patient experiencing the symptoms of stroke when presenting at an emergency room for treatment. Assuming the facility is not a stroke center, with enhanced diagnosis resources and treatment options for combating the effects of ischemic stroke, one’s prospects for full or partial recovery could well depend upon the confidence in and willingness of the E.R. physician to administer tissue plasminogen activator or "tPA," a thrombolytic agent, capable of recanalizing a passage through an arterial clot in the brain tissue.

    Although the use of tPA is recommended by the American Heart Association as a first line treatment for ischemic stroke the use of the drug is controversial because of significant risk of inducing intracranial hemorrhage and other organic damage in a small but significant number of patients.

    Please remember, as with all our articles we provide information, not medical advice.
    For any treatment of your own medical condition you must visit your local doctor, with or without our article[s]. These articles are not to be taken as individual medical advice.

    *Tune in later for Survey suggests more than two.

    Deepen your understanding of "medical malpractice"... www.MedMalBook.com

    For more health info and links visit the author's web site www.hookman.com