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.

Saturday, October 07, 2006

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
  1. awesome (very tough to get into, especially on a weeknight; no reservations) and
  2. five minutes from my house.
I figured the dues I've been paying all these years was enough to cover the cost, ("free") to assuage my hypertrophic sense of integrity.

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
It's not really "broken." Capitation is/was a way to shift the risk of having to pay for a doctor's visit away from the insurance company and onto the doctor. Somehow or another back in the early '80s enough people were fooled, but have since wised up. If no one's willing to take it on, capitation won't work. That's why it's fading away. It's evil gatekeeper step-sister, referrals, are alive and well, though it's quite clear by now that they've devolved into merely a way for insurance companies to deny payment if all the hoops haven't been jumped through properly.

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
Bullshit. Pay me a reasonable rate for what I do and I'll be happy as a clam. Again, though, no one could say anything because the speaker was on a roll; examples, studies; none of which sounded quite right, but I didn't have an internet connection in front of me to google up data with which to confront him. Then he moved on to the meat of his talk:
  • Fee for service has no incentive for quality
  • Fee for service + bonus/incentive
  • We need to reward quality
WTF? At no point in this talk -- or in any other P4P talk or discussion I've ever heard -- was the word "Quality" ever effectively defined in the context of medical care. I actually had a theorem in the early days of managed care and their black box bonus calculations: The more times the word "Quality" appears in a document, the more bullshit it is.

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.)


At Sat Oct 07, 12:10:00 PM, Anonymous Anonymous said...

Glad you had a good meal . . .the "dog and pony show" sounds depressing.

At Sat Oct 07, 10:17:00 PM, Blogger Bo... said...

That dinner does sound delicious. And, being a Texan, I'd have been with the person who was sopping stuff up with bread, only I'd have hoped for a biscuit. Anyhoo, about the "quality of care" issue.... AAAARRGGHHHH!! We in home health care are faced with the reality that Medicare just might decide to start paying (or not paying) home health companies based on some type of "quality of care" ratings. My question to the cosmos is this: What ever happened to the term "Progressive Disease", aka Chronic Condition?? For instance, (and as you mentioned in your posting) there isn't a dadburn decent A1C in THIS COUNTY, but it ain't my fault, ya know? My patients are all addicted to Blue Bell Homemade Vanilla Ice Cream. And Medicare will also want to see that patients have improved in physical symptoms, like incontinence and shortness of breath. But I can't make them take Detrol or stop smoking. A nurse can only NAG so much. Anyway, I'll stop ranting here and go look for something to sop something up with, now that you've made me hungry.

At Sun Oct 08, 12:15:00 AM, Blogger Sid Schwab said...

I might have gone with a nice savignon blanc for the tomato and cheese. The rest of your thoughts are right on. I do, however, intuit that there are some doctors that have better outcomes at lower costs than others. Were it possible -- and I'm not at all sure it is -- it would be nice to see an effort to figure out the differences and encourage them. It seems a better approach to controlling cost than finding more and more ways to cut reimbursement. But no one wants to address the real issue: how much are we willing to pay for healthcare, and how best should we prioritize the dispursal. (A euphemistic way around the "R" word, don't you think?)

At Sun Oct 08, 12:59:00 AM, Anonymous Anonymous said...

And the guy did have a valid point about having loyal patients who adore you but still haven't had mammograms and colonoscopies,
Isn't screening a patient's choice? Yes, colonoscopies can prevent cancer. Yes, mammograms might diagnose one of those cancers that are destined to spread before they become palpable, at just the right time. But the probability of an individual benefitting is small - less than 1/1000 after 10 years of mammograms, for example, and this is a pretty optimistic estimate. And screening has risks. Like overdiagnosis, for example, in case of mammograms. Like longer period of "being sick" if the cancer is so aggressive that early detection doesn't make a difference in the course of the desease. Like biopsies for false positives.

So if a rare patient feels that for her personally a higher chance of becoming a cancer patient, for example, is too high a price to pay for less than 1/1000 chance of having her life saved 10 years from now (forgetting that we are talking about desease-specific mortality and not
all-cause mortality
), how are you going to convince her? Assuming she is really informed, should you waste the precious time of the visit to try to get her to change her mind?

And what is quality? Openly discussing both benefits and risks of screening or just using scare tactic to get more patients screened? If you are not mentioning the risks, if you using relative mortality reduction and not mentioning the real chance of your patient benefitting, are you not misleading the patient?

At Sun Oct 08, 08:36:00 AM, Blogger Big Lebowski Store said...

You're making me hungry.

At Sun Oct 08, 03:18:00 PM, Blogger Dr. Rob said...

We are due to get a $25,000 bonus this year (per doctor) from Bridges to Excellence and BCBS of SC due to our use of EMR and focus on quality. This justifies the fact that we have spent more time seeing patients and have seen less patients per day than most FP's.

Our A1c rate is over 80% in the past year and our average A1c is under 7. The average LDL for my diabetics is 97.

My point is this: Whine and gripe all you want, but P4P is coming (I have high contacts near to those who make these decisions) and doctors should prepare for it. The consensus is that bonuses should be large to encourage doctors to engage in it.

The advantage of EMR is that it does not make claims data the main measure and takes the insurance companies out of the driver's seat. If the medical community would stop resisting and take on the task of shaping it to our greatest benefit, we may actually see a better life. Instead of worrying about how we are going to be shafted by a P4P, we need to make sure we control the conversation. I really believe that P4P gives good PCP's the opportunity to take back medicine. If we have the quality data, we have what businesses, insurers, the government, and patients all want. We can minimize the number of referrals to cardiology if we manage the cholesterol well and get our patients on the proper medications. In doing so we can decrease cost and increase quality. Do you really think that preventive medicine is not a smart thing to do? Do you really think it does not save money to prevent MI's rather than treat them?

I am sorry to rant, but the present system shafts good doctors and patients by discouraging us from spending time and focusing on doing a good job. Instead, we are encouraged to choose between making a good living or doing a good job.

Even increasing reimbursement in the current FFS system just makes bad doctors richer (again by making high-volume mills even more profitable).

The main problem is that there is mistrust by doctors at who is making the decisions about P4P. The solution is not to steer away from it, but to become influential in making sure it benefits rather than hurts us.

OK, this rant was too long and I am done. Awaiting counter-rants.

At Sun Oct 08, 07:26:00 PM, Anonymous Anonymous said...

. We can minimize the number of referrals to cardiology if we manage the cholesterol well and get our patients on the proper medications. In doing so we can decrease cost and increase quality.
So every doctor will try to get every patient with slightly elevated LDL on statins even if this particular person's 10-year risk of heart attack is < 1% just to get the numbers right. If the P4P guidelines only cover people with high risk, like diabetics it would be one thing. Otherwise, you'll end up putting plenty of healthy symptomless people on lifetime drugs in order to prevent one heart attack - do you think it will save money? (If P4P is coming maybe I should invest in drug companies after all?)

It happens already, but at least now, the doctors respect our right to choose. With P4P doctors will be loosing money for every patient with LDL 4 points above guidelines (even those with 10-year heart attack risk of 1%). A 40-something ballet teacher with no family history of heart desease and normal ratio, albeit slightly elevated LDL is complaining of muscle side effects that interfere with her ability to do her job (saw this woman's post on one of the forums) - "what would you rather have: a heart attack or muscle pain?". No explanation of the actual magnitude of benefit for her; after all if you mention that you are only talking about .3 percentage points in ARR, a patient might refuse and here goes you P4P. "It'll reduce your heart attack risk by whopping 30%". Very few patients would think to ask "n% of what number exactly?" Incidentally, maybe P4P should also evaluate physicians on providing honest and accurate information (to the best of the existing evidence) to the patients and respecting their right of informed refusal? Anybody thought of making this one of the criteria?

Do you really think that preventive medicine is not a smart thing to do? Do you really think it does not save money to prevent MI's rather than treat them?
Rob, have you done any calculations? You keep saying everywhere that it'll save money but never show any numbers. You keep forgetting that many people get treated for many years for one heart attack to be prevented and ignore any post that points it out for you. If it was not an immediately fatal heart attack (like my 2nd cousin's husband who just dropped dead or figure skater Grinkov), you'll save money on treating this person for this heart attack. You are not saving money on people who wouldn't have had a heart attack even without the drugs or whose heart attacks were not prevented. The person whose heart attack you prevented, by the way, may live longer and die from something else that might be more expensive to treat - unless you found a way to make us all immortal and eternally young. If so, pray tell us. The "purely money" aspect sounds cold but it is important since if enough bureacrats believe that all popular preventive measures save money, they might just try to penalize patients that exercise their right to refuse. The thought scares me to death which is why I always comment on these threads.

Whether or not it is cost effective depends on absolute risk reduction for a particular person. For diabetics or people who already had heart desease it may well be (although if someone doesn't take drugs and dies sooner, will this person save money or use more of it?) But when you are talking about measures with small absolute benefit, it should be individual choice. As a patient I have a right to decide for myself whether certain small risk reduction worth the risks or side effects for me or not. I don't want an incentive for a doctor that would depend on the choices I have a right to make. I want an incentive to provide accurate informatio but without the vested interest in my decision.
Talking about prevention. Do you think if this conversation had taken place before 2002, number of symptomless 60-year old patients on HRT for heart desease prevention would have made it into the P4P criteria? Rob, have you read the editorial on arrogance of the preventive medicine?

At Sun Oct 08, 09:38:00 PM, Blogger Fat Doctor said...

P4P is creeping into our faculty meetings. I fear we will find it integrated into our academic salaries, leaving little time for research or (God forbid) teaching. I am not a salesperson. I am not a factory worker. I am a physician. Who will judge my performance best? I hope it remains the patient.

At Mon Oct 09, 12:14:00 AM, Anonymous Anonymous said...

If it ever gets to surgery, its really going to be a disaster. It's very easy to tell an elective case to go elsewhere if they are high risk. "You know what, I just don't feel comfortable." "Oh you are a poorly controlled diabetic. You'll have to get someone else to do your surgey." Then on to the next patient that isn't high risk.

At Mon Oct 09, 04:28:00 AM, Anonymous Anonymous said...

Seems to me that the patients who really save insurance companies money are the the ones who just die, which makes me question ANY direction/control from medical insurance companies for keeping patients alive and healthy. Yes? No?

At Mon Oct 09, 01:14:00 PM, Blogger Dr. Rob said...


Yes, actually I have looked at the facts and here is the data I have seen:
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 ( 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.

I have never advocated treatment outside of guidelines (Your claim that treatment of a person with 1% risk with statins would be mandated by P4P is false). In fact, studies have found that if patients are left to decide if they should be on a Statin drug, only 10% of those who needed them got them, and only 10% of people who started taking them actually needed them. This is the main reason Mevacor was not put as a "behind the counter" drug last year. You harp on the fact that we would be "penalized" if we did not get the 1% patient in range. What P4P program out there does this or even suggests this?

Your comment regarding 1/10,000 Mammograms is questionable. From, the following statement is regarded to be the best current information:
Eight randomized controlled trials have been conducted on breast cancer screening, all using mammography with or without clinical breast examination [12]. Results of all trials showed a protective effect among women ages 50 and older; a meta-analysis found a significant 34 percent reduction in breast cancer mortality by seven years of follow-up

My main point was not that P4P was the solution to all of our problems. Instead, I think our main focus 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 we 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.

I have 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 my opinion) but the system that does not reward good care, but instead rewards doctors who spend as little time as possible with patients. As physicians we should not let others decide on this issue, but instead understand that this change is inevitable and so we need to make sure it does not have the problems you fear.

Dinosaur: what are your thoughts on this? Do you really think, like diora, that prevention is not all it is cracked up to be? It seems to me that this flies in the face of our training in Family Medicine or Internal Medicine. Is it really unproven that preventing a heart attack through use of ASA, and proper cholesterol control is a better way to spend resources than letting them have a heart attack?

BTW, both my mother and sister had routine Mammography and were diagnosed with Breast CA. I have something personal invested in this.

At Mon Oct 09, 04:40:00 PM, Blogger #1 Dinosaur said...

Rob and Diora: I agree with both of you, in sequence as opposed to in parallel. If you don't mind, I'll use this for tomorrow's blog fodder.

In a nutshell, though: Rob: preventive care is useful and good. Yes, I "believe" in it (given that it's not a religion, I have a problem with that verb), but I also think that patients should have the final say -- with appropriate counseling, which too often goes unreimbursed. I don't want to be penalized (or fail to be rewarded) when my patients make choices with which I don't agree.

At Mon Oct 09, 07:05:00 PM, Anonymous Anonymous said...

Your comment regarding 1/10,000 Mammograms is questionable. ... Results of all trials showed a protective effect among women ages 50 and older; a meta-analysis found a significant 34 percent reduction in breast cancer mortality by seven years of follow-up
Rob, do you know the difference between absolute risk reduction and relative risk reduction? 34% reduction in mortality is a relative number based on what a person's actual risk of dying from breast cancer is (note, not getting breast cancer but dying from it). Look here for example (for women over 50 section):
In our meta-analysis of results from all age groups combined, we excluded the Edinburgh trial (which we rated as poor) and used the results from both Canadian trials. The summary relative risk was 0.84 (95 percent CrI, 0.77 to 0.91), equivalent to a number needed to screen of 1,224 (CrI, 665 to 2,564) an average of 14 years after study entry.

At Mon Oct 09, 10:15:00 PM, Blogger Dr. Rob said...

Yes, I actually do know that. I also know that 1 in 7 women will get breast CA in their lifetime and that in 2001 42,100 women died of breast CA in the US. On the same website you sent me to (from AHRQ and USPSTF) the following statement was made to summarize findings:

What Does the Current Task Force Recommend?

The current U.S. Preventive Services Task Force (USPSTF):

* Recommends screening mammography every 1-2 years, with or without clinical breast examination, among women aged 40 and older.
* Recommends women should be informed of potential benefits, limitations, and possible harms of mammography in making decisions about when to begin screening.
* Concludes that there is insufficient evidence to recommend for or against routine clinical breast examination alone to screen for breast cancer.
* Concludes that there is insufficient evidence to recommend for or against teaching or performing routine breast self-examination.

You are, however, avoiding my main point, which is that the current payment system is broken, CMS is dead set on fixing it via P4P, and we had better not spend too much time complaining about it but instead find a way to make it scientifically sound. Your point of preventive studies needing a good foundation is well taken. I agree. I just don't think that justifies an across-the-board condemnation of the concept of P4P.

Recent things I have read have suggested that 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, I 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. I do not disagree with that concept. I recently went a talk where they were talking about measuring such physician behaviors on an EMR system so as to accurately record the intent of the physician. A recent Annals of Internal Medicine article addressed that very issue in diabetics (sorry, I don't have the reference, but go to my blog on and I do site it there).

You argue that P4P should be fair. I agree. But the current system is extremely unfair. As a pediatrician, I am paid less for newborn resuscitation than the OB is paid to do the circumcision. The current system favors procedures over thinking. The current system favors reaction over prevention. The current system favors quantity over quality. How else are you going to fix it besides starting to recognize that not all healthcare is the same quality and should be paid as such? I can demonstrate quality numbers and am getting paid (finally) to do so. I see this as more of an opportunity than a threat for primary care.

At Mon Oct 09, 11:43:00 PM, Anonymous Anonymous said...

Rob, recommendations are based on evidence that there are indeed lives saved. I am not argue with that. Recommendations don't make the probability of an individual benefitting larger than it is. I am not argue against screening. I am arguing for what that women have a right to know both benefits and risks and to decide what is right for them.

Potential benefits for an individual are best expressed as the number needed to screen or absolute risk reduction. RRR is meaningless out of context of one's risk. Total number of people who get cancer is irrelevant since mammograms since most breast cancers are curable even if detected later, some are indolent and some are too aggressive. Early detection makes a difference for a subgroup of cancers which is why NNS or ARR are what is important. USPSTF gives NNS based on the analysis of all available studies. Why not tell it to us?

Some doctors, lilke this well-known radiologist say essentially the same thing - that women should be given complete information. This little virtual mentor article on informed refusal (it is not about mammograms but it is relevant to the subject of screening) also talks about individual right to decide and screening as a choice vs as a religion.

By the way, 1 in 7 (isn't in 1 in 9?) is a cumulative lifetime risk if every woman lives until the age of 85. Most of us die before that age. NCR website gives estimates based on age which are more accurate. They also give mortality numbers as well as PDQ Summary of Evidence.

Incidentally, if you bother to read the studies analysis in detail, you'll see that 34% estimate is high. Since there haven't been any new studies, this is just another estimate based on what they included or not.

My 1% and statins came from personal experience (yes, it is anecdotal but it was according to guidelines). A few years ago I had an LDL that was about 4 points over the guidelines for my risk factors (164). My HDL was 54 and triglicerides pretty low. I am slim-to-normal (BMI of 22) and active, and at least according to the calculator on the AHA website, my 10-year risk of heart attack is under 1%. Yet because of the guidelines my doctor wanted to prescribe statins. I said 'no', and got LDL down to 134, HDL up to 70 on my own(actually I was on norithendrone acetate at the time and it messed up my ratio - I figured it out on my own, most doctors are not aware of this little side effect). I guess the doctor didn't think suggesting lifestyle changes because I was already thin. Also, the other day while in my health club, I noticed a JAMA magazine on the magazine shelf. I took it and saw an article discussing some woman with risk of 1%. I am afraid I don't remember which issue it was but it was fairly recent.

As far as your links about cost-effectiveness: most of them are about preventing death (agreed at start of my post) or secondary prevention like diabetes or people with heart desease (also specifically agreed with in my post). I was talking about primary prevention and money saved (or not), not lives saved. None of your references address this. One that does doesn't include (at least based on the limited information) look at the number of all people screened+evaluation of false positives+treatment of overdiagnosed cases (if any) vs savings on those who get less treatment.
As someone above said, if we die right away we save insurance company money.
By the way, I strongly recommend this book. No, it is not some crackpot selling vitamins; as pretty positive reviews in most medical journals show.
Time to go to sleep.

At Tue Oct 10, 08:53:00 AM, Blogger Dr. Rob said...

I think we agree more than we disagree (as usual) and I am happy that we have gotten to that point.

I strongly think that true Evidence based medicine is what is needed and that patients should be given the proper information (PSA testing is the best example).

As for your cholesterol, your physician was following a single guideline and not looking at total CV risk. There are guidelines based on that as well. We calculate a CV risk (Framingham) on all of our folks with high cholesterol, hypertension, and those here for routine well-care. I start Aspirin at 7% and a statin at 11% (based on a recent article). This is a good example where simplistic guidelines can hurt at times. However, the studies show that even Post-MI, a substantial percent (I think it was 1/3) were not put on a statin simply because doctors don't think about it. Your type of example is in the minority compared to these bad cases (more harm comes to them than would have come by unnecessarily using a statin).

I will look up that book (although my time is limited).

At Fri Oct 13, 12:01:00 PM, Anonymous Anonymous said...

If blood pressure is up and the doctor responds appropriately, he/she should be credited for doing the right thing, regardless of the outcome.

Apologies for bursting into the conversation at this late date, but what scares me as a patient about P4P is in that sentence: who definies "appropriately"?

I saw my doctor last week for my high blood pressure, as I do every 1-3 months depending on whether we've been tinkering with the meds or not (it has taken a while to get on an even keel after my last pregnancy). It was up, but instead of adding a medication/upping a dosage, he elected to just have me come back to have it checked again in a few weeks. He did this presumably because he knows me, he knows what's going on in my life, and knows that the stress level around here lately is unusually high. He gave me time to make a few adjustments, like getting more sleep and getting back on my exercise plan (why is it that the things that will help with the stress are always the first to go when I get stressed?), before resorting to more drugs.

Was what he did "the right thing"? I sure as hell think so. But will the P4P criteria think so? Or will that high reading come back to bite him in the checkbook if he waits a few weeks to prescribe something? (And you know, I'm not sure he'd care whether it did or not, but I hate the idea that it might, and I certainly don't expect doctors to work against their own financial interests. But then again, I'm all for paying them properly in the first place.)

These things worry me. It seems like a loss of autonomy for both doctor and patient, and things are bad enough in that regard as it is.

At Sat Oct 20, 12:01:00 AM, Anonymous Anonymous said...

My group is considering 20 percent p4p , and that seems pretty high
Any thoughts out there

How many cases to date have their been of physicians actually exploding into small pieces with this p4p>


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