NEJM "Perspective"Nov.2,2006:Misleading soundbite for P4P- "Shift from autonomy to accountability"

Dr. Elliot S. Fisher is the author for the NEJM piece "Paying for Performance-Risks and Recommendations" (NEJM 355:18 1845). Dr. Fisher has published many articles documenting the "remarkable variation in performance" by the players in ambulatory and hospital based care so we should not be surprised that he favors doing something about it-namely pay for performance (P4P).

Amazingly, after listing some of the major concerns about P4P he dispenses with them by simply saying that the concerns were discussed in a report by the Institute of Medicine (IOM) but that the IOM committee,of which he is a member" then "strongly recommended moving forward with pay for performance." This is a curous argument, indeed, that lists serious problems with the proposal, offers little reason to accept it (he does say payers are "demanding accountability") and then strongly recommends it. The arguments against P4P that he briefly covers are:

1.Concerns about the underlying goal. He says physicians fear that cost control will be the only focus.

2.Are the [quality] measures adequate? He says in part [medical care] "often requires a careful balancing of risk, benefits and patients' preferences, not rigid adherence to clinical guidelines."

3.Is implementation feasible? He acknowleges that for small office practices "costs will be high"

4.Could there be unintended consequences? Such as avoiding sick or challenging patients. (You think there might be a problem if physicians start avoiding sick patients)

Fisher then points out the funding problem. He proposes that the increased funds to "reward" (aka bride" docs for doing their job would be derived from cuts in the CMS programs so that " some providers would see little or no increase in fees."

Fisher then tells the readers that the IOM committee recognized that the evidence underlying P4P is weak and that unintended effects are possible and therefore the federal government was advised to have an effective monitoring and evaluation system in place to recognize potential harms and correct them. This would be a first- a government system that includes some sort of super-system to monitor itself and make mid-course corrections as it goes.

He closes with the claim that the "shift from autonomy to accountability" seems inevitable. This misleading and fradulent semantic ploy is reminiscent of the bogus term "managed care". Of course, physicians are already accountable-to their patients as well as to medical boards of examiners just as care was managed by physicians long before third party payers used the managed care mantra to cut costs.