Blog | Tuesday, August 14, 2012

What if the Gettysburg Address were ranked by pay for performance?

Why does pay for performance (P4P) make most physicians reach for Maalox? I have devoted a good portion of this blog's real estate to dismantling the fallacy that pay for performance improves medical quality. It's easier to argue that this clumsy and robotic approach diminishes medical quality by incentivizing physicians and hospitals to game the system to maximize their quality scores.

When an irritating high school student raises his hand and annoys the teacher with the inquiry, "Is this gonna be on the test?" it is a forerunner of the concept of pay for performance. The Ivy League seeking student won't study material that he knows won't appear on the exam.

Similarly, physicians and medical institutions will focus their attentions on achieving those outcomes that will be measured and graded, which might be at the expense of patients who "are not on the exam." For example, if irritable bowel syndrome isn't being measured, but GERD is, then will these patients be treated the same? Beyond this, I reject the concept that medical quality can be reliably measured and quantified.

There's a Renaissance painting hanging on a museum wall. Is it a masterpiece? Since it's tough to measure and judge art, should we use a ruler to measure the perimeter of the frame and consider this to be a quality surrogate? Absurd, yes. But, if you buy into this fantasy, it makes it a lot easier to measure quality.

Why shouldn't we apply the P4P concept into other professions. Not surprisingly, folks won't speak out against pay for performance until they are sagging under its yolk. Consider the following P4P extensions:
--Teachers' quality is judged by students' attendance
--Musicians' quality is graded by ticket sales
--Congressmen's quality depends upon approval ratings
--Meal quality depends upon weight,
--Book quality depends upon # pages

This is the same silliness that is being imposed on the medical profession. Sure, they can present P4P to the public as rational policy, but no slogan can sanitize the scheme. Of course, serious reforms in the health care system are needed, including a hard look at how physicians and hospitals are reimbursed.

Too often, the interests of the medical community and those we serve are misaligned. However, to force P4P on us and then use the results to reward or punish us financially is capricious, unreasonable and fallacious. Perhaps, even the government knows this is not a true quality initiative, but a poorly disguised cost control cudgel.

Is this blog post any good? How can we grade it? By the number of comments? Number of retweets? Why agonize. Let's all agree that a blog post's quality can be measured by the word count. Here's my suggested metric for number of words and how they rank:
1 to 100, Poor
101 to 199, Mediocre
200 to 300, Lousy
301 to 400, Below average
more than 400, Superb

If the Gettysburg Address is graded using the above schema, we would see how overrated this speech is. The reason we have elevated this speech into the pantheon of American rhetoric is because we didn't have an available grading tool that would have shown us that Lincoln's remarks were ordinary political drivel. Some presidents have all the luck.

Let us hope that pay for performance shall perish from the earth. It is altogether fitting and proper that we do this. This post by Michael Kirsch, MD, FACP, appeared at MD Whistleblower. Dr. Kirsch is a full time practicing physician and writer who addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.