DrRICH's posting on P4P is a masterpiece and it is only Part One. I have ranted on and on about P4P here wherein I seconded the notion that it was unethical and as such physicians should not be negotiating about the details of the process and here wherein I discussed the disastrous results of an insurance carriers P4P program in Seattle. His posts delve into more sweeping and fundamental aspects.
He tackles the Axiom of Industry that states:
Standardization of any process improves quality and reduces cost.
The axiom may make some sense in processes involving making widgets and it that setting may be able to actually increase quality and decrease cost but for the most part medicine involves processes involving living human beings and their diseases both of which vary widely along multiple dimensions making , for example, treating someone with heart failure as different as it could be from making widgets.
P4P is only part of the current landscape of medical practice which is dominated by managed care. DrRich offers a description of and an insight into this world in which words may not mean what they seem or are usually taken to mean and one in which the goals of the physicians and the managed care companies could not be more in opposition. Simply put, if physicians do their job they may well spend the insurance company's money, while if the insurance company is doing its job it will not spend money.
Practicing physicians who take the time to read his "Manged Care in an age of covert rationing" will never look at what they do in the same way again and if medical educators do not make its reading mandatory they have little defense against the accusation of dereliction of duty.