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.

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