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An Excellent Reader Comment On P4P (Pay for Performance)


Stanley Feld M.D., FACP, MACE

The costs of healthcare system have become unsustainable. There are many ways to reduce the costs in a sensible way. Pay for performance is not one of them.

President Obama and others have concluded that the way to reduce the costs is to change the way physicians are reimbursed.

President Obama is ignoring the fact that physicians receive only 10 to 15% of the healthcare dollars spent.

Who is the rest of the money going to?

Pay for Performance (P4P) is stupid idea to me. It sounds good to some.

P4P failed to produce cost savings during the major pilot program by undefined criteria. President Obama is rolling out the program to the rest of the country because he and his healthcare staff believe in it.

In my opinion P4P will only increase the cost of healthcare.

I offer President Obama a piece of advice. He should listen to retired physicians who practiced medicine for many years and understands patients’ wants and needs.

It is entirely possible that President Obama wants to collapse the healthcare system and have the government become the payer of last resort. Then he can create his beloved “single party payer” healthcare system.


Medicare is a “single party payer” in its present form is unsustainable and will disappear in 2016 or 2021. The addition of another 30 million people to its roles will make it less sustainable.

The problem with a single party payer system is that it will not work in America. It is turning out that it does not work in England and many other countries.

A retired radiation oncologist sent me this comment about the Pay For Performance (P4P) concept.



Now there's an excellent example of a term that sounds good but, absent a definition of the second "P", has no meaning at all.

I haven't heard anybody address that issue in a way that could be understood and accepted by all of the parties at interest.  Patients, physicians, hospitals, and insurance companies might be considered in the same light as the proverbial blind men describing the elephant of performance.

Perhaps, instead of "evidence-based medicine" we could look at developing the concept of "goals based medicine". 

Yogi Berra is credited with the thought, "If you don't know where you're going, any road will get you there". 

If the second "P" stands for performance, the question is begged, "Whose performance?" The assumption is made that the party doing the performing is the physician, I suppose. 

If that is the case, how is performance to be measured? 

Patient satisfaction? (pretty subjective).

Compliance with some set of guidelines? (If so, whose guidelines?)

Restoration of health of the patient?  (Now there's an interesting idea, that sounds pretty good, but must take into account the state of health being experienced by the patient before the current illness began.) 

 Quality of life? (Who defines that?) 

 Relief of symptoms?  (Pretty easy to assess, but different patients will define the severity of symptoms differently, and nobody else's definition really matters to each one of them.  People "suffer" differently, and some of their suffering is culturally derived.)

 Extension of some number of life-years?  (Quality adjusted, or just more years?  Who can tell?) 

Almost never, in the initial transaction between a physician and a patient and family is there any conversation about the goals or expectations to be accomplished in the experience the "system participants" are entering into and sharing. 

I would suggest that such an interaction might be the place to begin to define "performance".  Were the expectations met?  If they were, we have done our job.  If they were not met, there is either more work to be done in the current relationship between physician and patient, or there is a need for the formation of a new relationship between the patient and a new physician. 

Left unsaid is that such a discussion of goals and expectations, if held as early as possible in the relationship, may be the time for the physician to share with the patient what is capable of being accomplished, in contrast to what is expected to be accomplished.

Only when these terms are understood by all of the parties, can "performance" be adequately measured,

If "P4P" becomes the way services are valued, it is the only rational process through which the transaction can result in fair compensation. 

Bureaucrats sitting in offices far away cannot do this, only those directly involved in any clinical situation can. 

And, to makes matters more difficult, every clinical situation will differ from every other clinical situation in one way or another.


This physicians comment is an excellent argument for a Consumer Driven Healthcare System. Consumers must have the right to pursue their own destiny and be responsible for their own choices.

Consumers must own their healthcare dollars even it those dollars are given to them by the government. Consumers must have a financial incentive to be responsible for their own health and healthcare needs.

My Ideal Medical Savings Account accomplishes this. It can provide first dollar coverage to all at a lower cost to the healthcare system presently and motivate Americans to have a healthier life style further reducing the cost.

Mandates do not work!

The opinions expressed in the blog “Repairing The Healthcare System” are, mine and mine alone. 

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