Blog | Friday, July 11, 2014

Does pay for performance measure medical quality?

If you read this blog, then you likely know about the scam known as Pay for Performance (P4P). This program not only fails to deliver on its stated mission to improve medical quality, but it actually diminishes it. For a fuller explanation on why this is true, simply insert ‘Pay for Performance’ into the MD Whistleblower blog‘s search box, and grab some Rolaids.

In short, P4P pays physicians (or hospitals) more if certain benchmarks are met. More accurately, those who do not achieve these benchmarks are penalized financially. I do not object to this concept. Folks who perform at a higher level should be rewarded accordingly. My objection is that the benchmarks that have been selected are arbitrary and too far removed from true medical quality measurements. Benchmarks have been chosen that are easy to measure even if these measurements don’t count for much. In other words, what really counts in medicine, isn’t easy to count or measure.

Consider the following physician vignettes:
• A surgeon advises against proceeding with surgery as he feels that in 48 hours recovery may begin.
• A pediatrician makes a series of phone calls to arrange for a social worker to become involved in a challenging home situation.
• A family physician tells a patient that a CAT scan is not necessary for his condition.
• An internist recognizes that a patient’s new symptom is a side effect of a recent medication, which he stops.
• An emergency room physician sees a patient with a cough and notices a suspicious mole on the patient’s back. He sends the patient to a dermatologist.
• A gastroenterologist carefully palpates a patient’s abdomen and discovers that the spleen is enlarged. This begins a path that leads to an unexpected diagnosis.
• An internist takes a thorough medical history letting a patient tell his story without rushing him or cutting off his responses.
• An oncologist doesn’t advise futile cancer treatment, even though it could be presented to the patient and family in a manner that they would accept it.
• A hospitalist communicates all relevant medical information, including unfinished or pending issues, to the internist who will be assuming care of the patient after hospital discharge.
• A psychiatrist saves a patient’s life who had contemplated ending it.

These examples illustrate what I think is very high quality medical care. But, since there is no way to reliably measure them, they don’t count in the Pay for Performance schema. So instead, the government and insurance companies will measure lots of dumb stuff and then dock us when we don’t measure up.

This has nothing to do about real medical quality, but it has everything do about cost control. If the P4P enterprise were paid on its performance, they would be out of business. Shouldn’t they have to be subjected to the same rules that they impose on the medical profession?

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.