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Wednesday, March 30, 2016

The progressive medical elite-nothing wrong with P4P that being smarter (and learning the latest buzz words)- won't fix

The professional medical elite have had to admit that yes, sometimes in the past the P4P projects haven't worked out very well but we can all learn from past mistakes and with a fresh set of administrative buzz words and by being really smart this P4P thing will work really well regardless of what past experience and human nature tell us.

That seems to be the view expressed by a spokesman for the American College of Physicians (ACP) who is  masterful in his fluency of  medical management buzz words the use of  which along with being really smart, and catalyzing cooperation between the various stake holders will lead to a new enlightened era of amazing P4P rules abrogating Goodhart's law and revoking human being's strong tendency to respond to incentives.

Quoting from The ACP Advocate Blog written by Bob Doherty,VP of governmental affairs for the ACP  in regard to rules for P4P

  "..we should figure out what works to help physicians achieve the Triple Aim, including better ways to organize and deliver care, and then judiciously apply a core, harmonized, and improved set of measures to track progress, while always being on the look-out for unintended adverse consequences." Also we need to "reimagine" things. Why does that remind me of Will Roger's  solution to the German U-boat problem?

It is always good to throw in the bogus  feel-good and pious Triple Aim phrase and "harmonizing" has a nice vague group think ring to it and who is the "we" to which Doherty refers.There was once a time when there were only two people in the exam room that could be considered stakeholders, the patient and the physician. Now the way medical care is discussed  and is practiced seems to find others in the exam room who have some stakes to hold. These invisible stake holders include  , of course, the third party payers and now more than ever the health care entity that employs the physician . 

 Dr. Christine K. Cassel, formerly head of the ABIM and the ACP and the National Quality Forum (NQF), expressed her  opinion  in the New England Journal of Medicine ( "Getting More Performance from Performance Measurements" Cassel, CK et al , NEJM 371,23 2014). I quote.

"All stakeholder groups are now invested in getting more  performance out of measurements ,which should ultimately drive the care improvements that patients need and deserve."

 Two professors from the University of Zurich, Frey and Osterloh present four major arguments against the use of P4P  ( see here for a summary).I quote some excepts:

"It would be na├»ve to assume that the persons subjected to variable pay-for-performance would accept the respective criteria in a passive way and fulfill their work accordingly. Rather, they spend much energy and time trying to manipulate these criteria in their favour.(  Ed:This is one of mechanisms underlying Goodhart's Law).

 ......Variable pay-for-performance tends to crowd out intrinsic work motivation.".

Don''t look to the opinion pieces by Cassel or Doherty for cogent analysis of these and other critiques of P4P.Boil the oceans.

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