Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Tuesday, October 10, 2006

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.


At Tue Oct 10, 11:24:00 AM, Anonymous Anonymous said...

From a patient's perspective ...

I'm not buying a product ... or at least I hope I'm not buying a product. I'm establishing a relationship. That relationship includes, or should include, trust ... I trust my physician to do and say the right the thing - I trust him/her to not be a marionette dancing to the tune of some large institution's financial goals ...

As medicine morphs more completely from being a calling into being a job, it will continue to lose its basic essence.

From my perspective - that's a frightening prospect ...

At Tue Oct 10, 01:27:00 PM, Blogger Dr. Rob said...

As it stands, physicians (especially primary care physicians) are under such pressure financially that they have to rush the care. This HAS ALREADY turned medicine into a job (or at least partly so).

So, do you feel that if quality were definable we should reward it? Do you agree with my point that the present system rewards spending less time with patients rather than more? I do agree that we should not start something if we don't know the reasons, but I disagree that "quality" is that ill-defined. Even my foil in the other post did not disagree with the fact that secondary prevention measures will cut the cost of healthcare in the long run.

We should as the question: why would insurance companies reward performance which is usually measured in the ordering of tests, studies, and giving of medicine? Won't P4P then drive up cost? Obviously the increase utilization is offset by something. They see a benefit resulting from the upfront cost.

I feel we should not do P4P where quality is not defined, but we should do P4P where it is clearly defined and the benefit is clear. I think in CAD, DM, Asthma, and HTN these things are clearly defined and the benefit of quality is accepted.

At Tue Oct 10, 05:11:00 PM, Blogger #1 Dinosaur said...

I disagree that, given a choice between being paid appropriately to provide quality care and purposely maximizing revenue by providing minimum care, most doctors would opt for the latter, as you seem to believe they would.

I'd much rather have my fees increased so I can continue providing quality care, rather than having some insurance company define "quality" in meaningless ways so that -- bottom line -- they can find me wanting and keep the extra money anyway.

At Tue Oct 10, 05:39:00 PM, Anonymous Anonymous said...

Hmmmm, what Moof said. And with my $1500 deductible, it's all about the relationship and trusting my doctor to do what is really needed for me.

I can't afford a bunch of unnecessary crap just so someone can dot an "i" or make some huge healthcare system happy. And I'd rather pay my doctor more in the short run knowing that in the long run it will actually cost less. Does that make sense?

At Tue Oct 10, 05:56:00 PM, Blogger Dr. Rob said...

I am not saying that most doctors are being greedy. I am saying that we are forced to choose between finances and quality. This is a bad position to be put between. If you don't believe this, look at the quality of care in the US.

Does A1c testing, eye exams, cholesterol testing in CAD patients constitute quality defined in a "meaningless way?" If you don't like being measured by that, then how do you define good medical care? Would you send your mother to someone who was compulsive about keeping up with the latest evidence standards, or one to whom it did not matter. The current payment system relies on the ability of doctors to forego money for the sake of quality. There is no other industry that requires a trade-off of income for quality. I am simply defining quality here as spending more time caring for your patient. You get paid less when you do that. It isn't right.


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