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Pay for Performance: An Attempt to Standardizing the Standards: Another Complicated Mistake. Part Seven

Stanley Feld M.D. FACP,MACE

In my opinion Pay for Performance (P4P) is code for decreased physician reimbursement. It also represents an attempt by healthcare policy makers to standardize the standards. We can remember Dr Petak’s experience with Blue Cross/Blue Shield of Texas. He was penalized for doing the right thing. He was using a benign medication works for infertile couples. The medication’s was not in the insurance industries algorithm. He saved the patient lots of procedures and the healthcare system thousands of dollars per patient. In thinking about it, quantification of the standards has little to do with the actual medical outcome.

Paying for Performance implies you are willing to pay more for quality medical care than you are for medical care that lacks quality. However, quality medical care has been defined artificially. There are many components to quality medical care. The first is the physicians’ performance and the second and most important is the patients’ performance. If the patient does not do what the physician recommends, the ultimate outcome, the patients avoiding the complications of chronic disease, will not occur. Presently, patient compliance with medication and treatment advice is 45%. None of the healthcare policy wonks thought of this when P4P was invented. Their goal was to impose measurable standards to measure physician performance. They have not developed standards that measure clinical outcomes. The actual clinical outcomes must also be link to social, psychological and financial outcomes. An excellent performance is helping the patients help themselves stay healthy and avoid the complications of chronic disease.

On May 27, 2007 the New York Times Magazine section Ann Hulbert published an
article criticizing the No Child Left Behind Program of President Bush. The title of the
article was THE WAY WE LIVE NOW: Standardizing The Standards
It made me think about what is going on in the P4P experiment. It also brought to mind the Pete Seeger song whose chorus is “When Will They Ever Learn.”

“The president’s signature domestic initiative, now due for its five-year reauthorization, was supposed to be a model of the hardheaded rigor it aims to instill in America’s schools. ”No ‘accountability proposals’ without accountability,” a Bush education adviser declared early on. So one of the most glaring legacies of No Child Left Behind is surprising: it has made a muddle of meaningful assessment. Testing has never been more important; inadequate annual progress toward ”proficiency” triggers sanctions on schools. Yet testing has never been more suspect, either. The very zeal for accountability is confusing the quest for consistent academic expectations across the country.”

There are endless problems reported in the article about standardizing the testing standards for children so that no child is left behind. There is a social science principle called Campbell’s law. ”The more any quantitative social indicator is used for social decision making,” the social psychologist Donald Campbell concluded in 1975, ”the more subject it will be to corruption pressures and the more apt it will be to distort and corrupt the social processes it is intended to monitor.” The article was referring to measuring the performance of public school on the basis of test scores. “With ”high stakes” testing, N.C.L.B. introduces an incentive not to cheat, necessarily, but to manipulate. Signs are that states define proficiency down while schools ramp up narrow test prep. ”Score pollution” — results that reflect intensive coaching — becomes a risk”.

I thought the purpose of education was to teach children reading, writing, and arithmetic. Learning the basics should teach children to think, and solve problems. The goal should not be to get high scores on standardized tests for the maintenance of school funding by the federal government. It represents a pay for performance model for education. In my view, it represents fuzzy thinking.

The author says, “The National Assessment of Educational Progress could serve as a model for a test that judges students’ ability to apply their knowledge and thus discourages rote coaching.” Learning by rote is an invention of policy wonks. In my view, it is not education.

“But recent experience — and Campbell’s law — argues against making test results the sole trigger of federal sanctions. Instead, the data would give states and school districts reliable information on where progress is, and isn’t, happening across the country, to catalyze their own strategies to boost achievement. Rather than cramming to reach an unrealistic target by 2014, states could be more like the laboratories of curricular improvement the country needs”.

The policy wonks ignored Campbell’s Law. They are repeating the same error in medicine with P4P. America sent Dr. Deming to Japan after World War II. He taught the Japanese the concept of continuing quality improvement. Why can’t we do this in education and medicine as well.

“Agreeing on common goals for what kids should be learning can free up teachers to focus more productively on how they could be learning better.”

Education, like medicine, also has two stakeholders. They are the student and the teacher. We have to create an environment of incentives to have both the teachers and the students responsible for their actions and excited about their goals. The methods in NCLB dumb down the system of education and have not produced results. In two words “it failed.”

I predict the same thing will happen in P4P in medicine. The clinical outcomes will be worse. Medical care will be worse. The healthcare system will be dumbed down. The patients will suffer. The healthcare system can not stand another disaster. The healthcare system has to focus on improving clinical outcomes for chronic diseases to avoid their complications. The system should not be imposing requirements on physicians to do certain measurements to get paid. This standardization is foolish. It will turn out to be counterproductive. The two main stakeholders are the patients and the physicians. They are both responsible for the patients’ care. The patients are most responsible and must drive the system. This is one of the arguments for consumer driven healthcare. Consumers are not as stupid as policy wonks think they are. Formulas such as P4P have to be taken out of the hands of the policy wonks and put in the hands of the patients. We must give patients the incentive to do it right by giving them control of their healthcare dollar.

In the treatment of chronic disease it is essential that patients become the professor of the disease with the physicians and their health care teams becoming the coaches that help the patients’ problem solve.
Since 90% of the healthcare dollar is spent on the complications of chronic disease we should be concentrating on developing systems of care (focused factories) that concentrate on the treatment of chronic diseases. The measurement of testing done has little importance. The interpretation of the test results is important. The clinical step taken will influence the clinical outcomes. Pay for Performance represents as perfect opportunity to once again demonstrate that Campbell’s law is true.

Unfortunately, it looks like P4P is a concept developed by technocrats to maintain their importance and value promoting another flawed methodology. It will create more dysfunction in the healthcare system. It is also an excuse for the government and the insurance industry to decrease payment and increase their control over the healthcare system. I predict P4P will increase cost of medical care and decrease the real goal which should be decreasing the complications of chronic disease.

We should be spending money on reimbursed the institution of systems of care that decease the complications of chronic diseases. This is not happening. Physicians must drive these systems of care for it to work. When patients control the healthcare dollar they will pay physicians to develop systems of chronic disease management.

Perhaps hospitals like to treat the complications of chronic disease. It helps their bottom line. Maybe the insurance industry wants an excuse to increase the price of insurance. Once again the goal of medical care system should be to keep people healthy. The emphasis of the facilitator stakeholders is to fix people when they are sick. This must change if we are going to fix the healthcare system.

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