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Monday, March 28, 2005

Pay For Performance, the latest bogus proposal from Third party "Players"

The latest buzz phrase seems to be "Pay for Performance" (PFP). Articles that discuss the topic often are ambiguous about what PFP means. How will performance be measured? That's the rub. Typically, studies which purport to measure "quality" measure the degree to which certain guidelines are adhered to, wherein quality equals conformance, begging the question are the guidelines even valid. "Performance" will, likely , in part, be "measured" in the same way.
Dr. Charles Francis, president of American College of Physicians, recently participated in a Pro & Con section in Internal Medicine News. The question was " would pay for performance result in better care" He was Pro. He implies that the market is demanding PFP to ensure high quality performance. The third payers are demanding it. How many patients have you heard express the idea that they are very interested in physicians being payed in part by their "quality" of care"? Patients are interested in the physician taking care of the problem at hand. Does anyone deny that the insurance companies, and Medicare are primarily interested in cutting costs? Follow the money. Don't judge a plan or activity by its purported mission, but ask what incentives and restraints does that entity operate under. The incentive of third party payers is to decrease costs.
Dr. Francis's opponent in this quasi-debate was Bruce Vladeck, former administrator of the Health Care Financing Administration. Mr. Vladeck , a non-physician,and he had the most cogent insight expressed by either participant. He said in part about physicians "To change behavior through relatively modest economic incentives is much less powerful than targeting the activities that make professions feel good about themselves-where their identity is closely tied"
While Mr. Vladeck does not explain how to do this, at least he realizes what , I think, most doctors are really about, our identity is tied strongly to doing a good job for our patients.
Unfortunately, to my ears, Dr. Francis's comments sounded like what an administrator of a insurance plan would say ( "...fragmented care,....helping to raise the bar on quality.. foster continuous quality improvement..to meet or exceed evidence based standards." The ACP seems to be the "Newest best friend" of managed care and the powers that be that hold the medical purse strings.


Anonymous said...

Does the ACP publish its annual report? Does it receive funding from any source outside of its own physician members or fee-paid educational activities it undertakes? Does it receive any funding from outside entities such as nonprofit "foundations" that themselves may receive funds from interested parties?

I agree with you. Follow the money. I suspect the insurers aren't looking so much for a way to pay for quality as much as a way to justify not paying for care that falls short of some index (preferably on they get to define) of "quality". Will factors such as demographics and patient non-compliance be factored into these assessments? Don't count on it.
When the real incentive is to rationalize not paying, any reason. properly rationalized, will do. That may seem cynical, but that opinion comes only from experience. And what self-respecting physicians' organization doesn't want to stand up publicly for "quality"? It's like Mom and Apple Pie.

Here's an alternative, if you care about quality. Invite an outside certifying oragnization, without ties to the insurance industry or to DMMS, to rate practices on relevant quality indicators. Make them specialty specific: glucose control for diabetes and referral for annual eye exams for internal medicine practices, or vaccinations and regular routine exams for pediatrics. Let the practices be rated the way Underwriters Laboratories or Consumer Reports rates things. Then let the insurers offer an incentive to their insureds to choose practices rated highly for quality: lower copayments or monthly premiums. If the quality indicators are meaningful, then better quality preventative care will also benefit the insurers. The patients have to be incentivized to choose quality for themselves and to pursue it.


lcwaddell said...
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