P4P and Other Nonsense
I just got back from a meeting tonight; a meeting of my state specialty society, not something sponsored by Evil Pharma (a term invented by one of their employees, to whom I happen to be married.) The main reason I went was because the restaurant was
- awesome (very tough to get into, especially on a weeknight; no reservations) and
- five minutes from my house.
The topic was "Pay for Performance", often abbreviated P4P. Somehow the idea is that doctors will take better care of patients if they're paid more. The State chapter had reserved us a gorgeous, cozy upstairs room with four tables each set for ten. There was a cash bar, where I bought myself a glass of merlot, and then helped myself to a scrumptious slab of mozzarella on a slice of tomato from the appetizer bar. I found a seat as my Academy Representative began her Update.
They're having conversations with the big insurers in our state; the ones who have us all over a barrel as they ratchet down reimbursements and pile on the denial hassles. Our Academy is making sure that our concerns are heard. They're talking to the insurance companies, and our legislators, and we should rest assured that our pain is being communicated to the appropriate parties. I helped myself to a plateful of delectable antipasto salad from the bowls placed on the table ("family style service") and savored the mixture of crispy lettuce, salty proscuitto, cheese and spicy vinaigrette dressing as I pictured the offices of whoever they're talking to at the insurance companies after the door has closed behind my Academy rep: soft chuckles, a gentle shake of the head, and on to the next order of "real" business. My concerns may be heard, but they ain't about to do squat about them. The Italian bread on the table was delicious; soft and freshly baked. As I spread it with a pat of butter and chewed the crunchy crust with pleasure, I realized that both the Insurance Exec and my Academy Rep were taking home regular paychecks; unlike me for the last three months.
The waiters filled the tables with platters of Chicken with Farfalle in Parmesan Broth, Salmon with Herbs and Lemon, Three-Cheese Ravioli (giant; al dente; in a scrumptious butter-cheese sauce) and Eggplant Parmesan. We passed the platters around and filled our plates as the main speaker began.
He was nice enough. Well spoken; confident; engaging; funny. He used to be a doctor, but is now working for some kind of healthcare company that doesn't actually provide health care. His power point slides had a nice sky blue/cloudy white background design, and he put forth bullet points that you couldn't really argue with. Well, you could, but he was such a smooth speaker it didn't seem polite to interrupt. A woman up front tried a couple of times, but he smiled knowingly and politely told her she was wrong. He began with:
- Capitation is broken
I noticed a lady at my table sopping up the ravioli sauce on her plate with a piece of bread. I reached for another piece myself and did the same, as another bullet point came up:
- Fee for service is broken
- Fee for service has no incentive for quality
- Fee for service + bonus/incentive
- We need to reward quality
You can talk about "outcomes" until the cows come home: what percentage of your diabetic patients have A1C's under 7%; how many of your hypertensives' blood pressures are controlled; all kinds of things. And the guy did have a valid point about having loyal patients who adore you but still haven't had mammograms and colonoscopies, so obviously "quality" doesn't always track with "customer satisfaction." But I still say that the central element of "quality" will forever remain fundamentally unmeasureable; 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: me and the patient. There are certain things I'm 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 I don't buy it.
I managed to calm down as the plates were removed and platters with Tiramisu and Apple Crisp a la Mode appeared. The ice cream had ribbons of caramel swirled over it, so I had a plateful of ice cream, caramel, apple and sweet pastry alone, so as not to risk contaminating it with the chocolate coffee flavor of the tiramisu. I took a clean plate for a slice of that afterwards.
The talk turned -- inevitably -- 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 you for. The lady up front pointed out that all the favorable data about the wonders of EMRs are from large organizations like Kaiser and the VA. The speaker again politely told her she was wrong, but neither she nor I had a laptop in front of us to Google him right or wrong. A man in the back spoke of the new EMR he had just purchased for $30,000. Once all the numbers were crunched, though, it turned out he was only going to see about $3,000 in P4P bonuses. The response, delivered somewhat more softly than the stentorian tones of the main presentation, was that his return was more likely to be in the areas of quality and lifestyle. I imagined presenting a proposal to an insurance comany -- 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."
I sighed, finished my merlot and headed home.
In the early '90s the buzzword was "vertical integration." Hospitals and health systems were buying up medical practices like crazy. 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. It didn't sound right to me then, so I did not sell my practice. Sure enough 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.)
This whole "pay for performance" thing doesn't sound quite right to me, for many reasons. I've been around long enough to be very wary in situations like this. When everyone seems to think something is so, but can't explain it in a way that it makes sense to me, either I'm stupid or there's something wrong with what they're saying. I have learned that I am not stupid.
But the dinner was delicious.
(More here and here.)