More P4P (Sigh)

There's an interesting discussion taking place in the comments trail of my opening salvo on the topic of P4P. Rob and Diora are going at it hard and heavy, but they're not actually discussing P4P anymore. They're locking horns over the value of screening tests in particular and preventive care in general, trading figures and citations. As it happens, I agree with both of them, at least on that particular topic: preventive care is a good thing, but patients should have the final say about all testing and treatments -- including screening -- in consultation with their physicians.

Why does P4P always seem to devolve into a discussion of preventive care? It's because P4P needs a way to measure what "performance" is being "paid" for (or "4"). Preventive care, screeening tests, immunization rates, concrete numbers like blood pressures and A1Cs are measureable, so that's what's measured. It's hard to argue that higher rates of evidence-based interventions aren't better than lower rates, so those are the numbers that become a proxy for "quality" as we all get sucked into meaningless discussions about the value of preventive care.

This whole thing is starting to sound more and more like the move in the early '90s towards physician practice sales to large hospital systems to create so-called "vertical integration." Remember what they said then:

• It's coming; you'd better get ready for it; it's inevitable, so you're going to have to deal with it.

Didn't make sense to me then and guess what: it never happened. We heard plenty of this, though:

• I/we/my practice did great/made a heap of money; glad we did it; couldn't be happier.

The first docs to sell their practices were happy at first. It was only when their initial four-year contracts came up for renewal (and the "system" was losing money because things weren't working out as advertised) that they found themselves behind the eight-ball, stuck with a tiny fraction of the negotiating power they had when the hospital was so desperate to buy the practice in the first place. Down the road, when the shortcomings of the model (foreseen by me and others from the beginning) became apparent, they were screwed.

Have you noticed that the biggest proponents of P4P are those who have found a way to benefit mightily from it? (And yes, I recognize the corollary argument: those who holler loudest are the ones who haven't made any money from it. So how much is legitimate criticism and how much is mere sour grapes?)

But Rob again makes the statement "Fee for service is broken," and again I say, bullshit. If that's the premise for all this P4P discussion, then we're just not starting from the same place.

Here's the bottom line:

The following statement makes no sense: "Pay for performance will improve quality of care," without defining "quality", "performance", and even "pay" and "improve." It is a bad idea to embark on a course of action without understanding the reasons for that action. Therefore unless/until someone can why P4P makes sense, I am not going to do anything (ie, go out and bankrupt myself by purchasing an EMR just for P4P.) Nor am I going to lose any more sleep over it.