Blog | Monday, January 8, 2018

May physician targeted performance payment finally receive its death knell


Long time readers of this blog know my disgust with pay for performance. P4P has many incarnations, all of which are harmful to patients and physicians. The blogosphere has ranted about this for at least 11 years. Search P4P on this blog and you will see the vast number of posts regarding this topic.

This week's Annals of Internal Medicine has a wonderful article and editorial that strongly indicts “value based payment”: Value-Based Payment Modifier: Outcomes and Implications and Changing How We Do Pay for Performance.

The editorial (VM refers to Medicare Value-Based Payment Modifier) includes: “Using a sound analytic approach (exploiting discontinuities in VM design by practice size and time), McWilliams and colleagues found that VM bonuses and penalties had no effect on the quality or efficiency of care delivered. These results are consistent with those of previous studies of physician P4P programs (2) as well as a larger body of evidence around hospital-focused P4P programs (3–5). All told, evidence that P4P improves care is scant.”

“Worse, the authors found that the VM likely has exacerbated existing disparities in care. Because the Medicare VM does not adjust for socioeconomic status (SES) or illness severity, practices that care for lower-income or sicker patients received greater penalties, essentially creating a reverse Robin Hood effect (6). Likewise, the MIPS is not slated to account for SES or illness severity, so it also might exacerbate disparities between organizations serving larger vs. those serving smaller proportions of vulnerable patients.”

One of our leading health service researchers (and prominent blogger), Harlan Krumholz, MD, tweeted: “I personally do not believe we should be measuring individual physician performance. It is about teams. It is about what we accomplish together. Technically and conceptually challenging to create assays of physician performance.”

We have made this point repeatedly for over 10 years. Yet, politicians and regulators seem enamored with “measuring quality”. Has anyone asked them to define quality? Sometimes you cannot measure quality because it has so many dimensions. Quality medical care varies tremendously from patient to patient. Sometimes successful palliation is the key dimension; sometimes making the proper diagnosis is the key dimension; sometimes helping the patient change their behavior (stopping illicit drugs, or smoking or drinking or losing weight) is the most important dimension; sometimes controlling their diabetes and delaying complications is primary. You can add many phrases to this.

Sometimes patients need reassurance. How do we reconcile performance measures with quality? Please never call them quality measures because no measure or combination of measures will adequately measure quality. I have often provided high quality medicine in my career, but unfortunately I have not always provided the highest quality medicine. But while I know that, I would defy you to measure it.

As MIPS (The Merit-based Incentive Payment System: Quality and Cost Performance Categories) impacts payment, it does so without an evidence base. We are expected to practice medicine influenced by evidence. Program like MIPS may influence how some physicians practice, yet we have no evidence on the impacts. Likely, we will see unintended consequences.

We finally have many voices calling for a hold on this ill-conceived plan. Hopefully we will see MIPS disappear, RIP.

db is the nickname for Robert M. Centor, MD, FACP. db stands both for Dr. Bob and da boss. He is an academic general internist at the University of Alabama School of Medicine, and is the Regional Associate Dean for the Huntsville Regional Medical Campus of UASOM. He still makes inpatient rounds over 100 days each year. This post originally appeared at his blog, db's Medical Rants.