Friday, March 16, 2007

More data showing why P4P will not work-planners undaunted

A recent (free without subscription) article in the NEJM presents data that indicate that the reality of medical care in the U.S. is such that the P4P will not work. Many Medicare patients- and I am sure this applies to non-Medicare patients as well- do not have their medical care provided by a single practitioner.

One problem that policy-wonk, medical planners have is they are dealing with people who live in a free country who typically exercise their choice about a lot of things including who they see when they are ill. If a person is not happy with their doctor-for whatever reason-they change doctors and sometimes they change doctors even if they are happy with the current physician.

In the course of a year a so a person may see several different doctors. This poses a problem for the P4P advocates-namely who should the patient be "assigned to" in terms of the rewards or the penalties of the pay for performance system. The study authors doubt how effective P4P will be in improving quality-for those of you who believe that is about quality. They also suggest maybe we need to assign patients to a given doctor.

The authors may want to review section 1802 of the Medicare bill which said:

" Any individual entitled to insurance benefits under this title may obtain medical services from any institution,agency or person qualified to participate."

Although we can find little comfort in that assurance since the government stopped paying any attention to section 1801 of that bill long ago:

"Nothing in this tittle shall be construed to authorize any federal official or employee to exercise any supervision or control over the practice of medicine..."


Of course, the way that medical care is actually"delivered" is only an inconvenient truth to the planners-something that needs to be restructured to better fit their plans for what everyone should do. That pesky freedom thing does have a way of interfering with central planing.The companion editorial-by Karen Davis, a PhD economist and currently President of the Commonwealth Foundation- suggests ways to changes things so P4P could work. Somehow, we could encourage doctors and patients to participate in a system more like that in which P4P might work and encourage the growth of large integrated systems. Then those systems could reap the rewards of a P4P arrangement. She then admits that P4P at best would be a intermediate step-an interim program- until the day when their bigger and better plan could be realized.Stay turned for details of what that might be.

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