More P4P (or: DB, You Ignorant Slut)

Somehow over the last two months since I began blogging (hard to believe that's all it's been) I had gotten the impression that DB, that Wild and Crazy Guy, was in favor of Pay for Performance. Where might I have gotten this idea?

There's this paragraph from his post titled What is Quality?:

Last week, SGIM sponsored a Quality Summit. During this 1 day meeting we focused our discussions on performance measurement and how should adjust for multiple co-morbidities. As the President of SGIM, I organized this conference and greatly enjoyed the intellectual stimulation during the presentations and the discussions that followed.

and a few weeks later, in Measurement: blessing and curse:

I consider myself partially responsible (emphasis mine) for the P4P crisis. I have participated in studies which examined “quality” as measured by adherence to performance indicators. While I am a minor player here, I have published literature on this “problem”.

I loved that post, especially the Albert Einstein quote:

"Not everything that can be counted counts, and not everything that counts can be counted."

and I commented enthusiastically on his blog. An email exchange ensued, in which Dr. Bob thanked me for my comments. I said "You're welcome" and commented that I thought -- perhaps because of his research interests -- that he was in favor of P4P. This was his answer:

[I'm] not proP4P. I am in favor of research which examines how we can help physicians improve their care delivery - 2 different concepts.

I realize he was probably just throwing together a quick response, but his exact words began eating away at me: "Research that examines how we can help physicians improve their care delivery."

I understand the concept of improving care. That kind of research usually uses terms like "evidence based medicine" and "best practices", and looks at the relationship between care given by physicians and outcomes experienced by patients.

Where does the care "delivery" come in? If I get 90% of my diabetic patients to an A1C below 7%, presumably I'm doing "better" than a doc who only gets 65% of his patients to that level. Why does it matter how I do it? What difference does it make if it takes me an hour of counseling twice a week for six months to get the patient into a healthy routine of diet and exercise, or three drugs plus insulin? I submit that the only possible distinction is (get ready for it) -- costs. Those drugs are costly; those visits take time, and time is my stock in trade, for which DB agrees I should be fairly compensated. Assume two potential clinical management strategies achieve the same outcome at different costs; anyone want to bet which one will be considered "better"?

I'm a solo family doc in full time practice, and while I welcome input on medical outcomes, evidence based medicine, and so on, I have to tell you that I don't grab JAMA the moment it drops on my doorstep and pore through it trying to figure out how to "improve my care delivery." Not many of my colleagues are either. When we get together for CME dinners, the casual conversation doesn't go, "Rats; I really need to ratchet up my care delivery." Reimbursement gets talked about, but only because we are being hassled to death instead of being fairly compensated. So why is this such a hot research topic?

Let's agree that DB is referring to "quality of care." Here's his definition of that, by the way:

• Diagnostic acumen
• Patient interactions (Careful explanations; Motivating patients (behavior change or adherence); Understanding the patient’s motivation)
• Management
• Interactions (Understanding how drugs interact; Understanding how diseases interact)

I don't see the word "cost" anywhere in there.

I submit that "quality" in this context is the unit of P4P (the unit of performance "4" which they are proposing to pay.) There is no other reason to discuss, define, or research "quality of care" (not the same as "best practices" "optimizing patient outcomes", or "evidence-based medicine.") Why study something that has no use except in constructing a P4P scheme, if you're not in favor of P4P in principle?

What seems to have happened is that insurance companies (and the government) have taken the lead in this, effectively saying to us, "We're going to do this. Either we'll define things like "quality" and "performance" ourselves (and then pay you for them -- or not -- as we see fit) or you can sit down at the table with us and have some input into how these programs are going to work." Forgive the outlandish analogy, but how different is it in principle from the Gestapo telling the Jewish Council in the Warsaw Ghetto to put together lists for deportation or they'd do it themselves? Because in the end it made no difference anyway, as they did what they wanted. As they will again, I predict.

There's my rant, DB. I guess I'm just on a mission from God.