An article published in the March 15 issues of the New England Journal of Medicine looked at pay for performance (P4P) programs, specifically the Medicare initiative, and discussed the difficulty in determing who should be paid the additional payment for quality of care.
According to a study by researchers at the Center for Studying Health System Change (HSC) and Memorial Sloan-Kettering Cancer Center (MSKCC), Medicare beneficiaries’ care is spread over so many physicians that determining which physician should qualify for additional payment is a moving target under current pay-for-performance (P4P) designs. Medicare beneficiaries are more likely to have multiple physicians, and the study found, about a third of the patients they would be held responsible for will switch to a different provider the next year anyway.
The NEJM press release said:
A Medicare patient seen by the typical physician in the nationally representative study was treated by seven different doctors in four different medical practices in a given year, the study found. And only about 35 percent of beneficiaries’ visits were with the doctor held responsible for their care under the most common P4P methodology used to assign patients to physicians. Moreover, for 33 percent of beneficiaries, the assigned physician and practice changed from year to year.
Using a variety of different methods to assign patients to physicians or practices, the study concluded that typically primary care physicians would be held accountable for 39 percent of the Medicare patients they treat and 62 percent of Medicare visits they bill, while medical specialists, who often provide more costly care, would be held accountable for 12 percent of the Medicare patients they treat and 20 percent of the total Medicare visits they bill.
The article suggests that if Medicare doesn’t identify the responsible physician until after the fact, the P4P incentives will not act as a motivator for quality of care. Incentives can help the return on larger investments, such as EHR. The author’s suggestion that the “responsible party” physician be identified in advance is contrary to how physicians work, as many primary care physicians no longer go to the hospital, leaving that to specialists and hospitalists.
This has always been the cunumdrum in paying incentives for quality care. A physician – and patient – may do everything “right”, yet the patient may become ill because of genetic factors or other factors beyond the control of a human being. Back in the 1980s, the much hated US Healthcare HMO paid bonuses to physicians who met certain preventive care targets for the panel of patients assigned to them. In that case, the physicians were paid a bonus for insuring that 85% of the eligible women had a mammogram on schedule, for example. The physicians were paid for their overall performance, not for what happened on an individual patient.
Someway, somehow, physician care is going to be monitored and measured. Our schools have the “No Child Left Behind Act and are tested to death. For physicians, I think we’re not quite there yet, but this administration is betting on P4P. For you, the strategy is long term. Start random audits of a sampling of charts. If you’re in a group,. look at the most common “things” you do, and compare how the physicians are approaching their treatment – which should be consistent. I’d also make a big bet on prevention, which is measurable, does impact outcome, and is profitable. In short, you want to be positioned as practicing quality medicine consistent with best pracitces – and be able to prove it.