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    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.

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