Stanley Feld M.D.,FACP,MACE
Unfortunately, the devil is in the details. P4P has devils in its details because of potential misuse of information technology. I will present of the many examples in endocrinology alone. The example of an application of P4P will make the concept of P4P seem ridiculous.
The insurance industry and the government have been trying for many years to define quality in order to measure quality care. They have asked healthcare organizations and healthcare administration organizations to develop the standards.
The American Diabetes Association volunteered for the Diabetes Mellitus Quality Improvement Project (DQIP) initiated in 1997. There were no physician organizations represented in this project initially. Unfortunately, this is not uncommon when one wants to develop standards or set reimbursement principles for the practicing physician.
If physician organizations wanted to have a seat at the table they could join. Physician organizations that joined were practicing clinical endocrinologists as well as others. Clinical Endocrinologists are most effective in treating diabetes because of their training and their clinical experience. Academic endocrinologists have much research experience. These academic endocrinologists know little about the challenges of clinical practice.
The steering committee, composed of representatives from four organizations (American Diabetes Association (ADA), the Foundation for Accountability (FACCT), the Health Care Financing Administration (HCFA), and the National Committee for Quality Assurance (NCQA) met, with the overall goal of establishing a set of diabetes-specific performance and outcome measures. The goal was to allow for fair comparisons of health care plans, stimulate quality improvement, be based on scientific evidence, and yet be user-friendly to payers and consumers. DIQP is funded by the HCFA portion of the Balanced Budget Act of 1997. The design of the Project was well intended but the outcome of the measures used by the insurance industry is punitive to physicians and patients rather than educational.
Few of the participants understood that compliance with these outcome measures was predicated on the patients making lifestyle changes as well as the patients adhering to medication prescribed and faithfully doing home blood glucose monitoring so they could effectively self-manage their disease. There is a 40-60% non adherence rate. In additional, even if the physicians give the recommended medications there might be subtle barriers in the clinical disease that renders the recommended medication ineffective in controlling the blood sugar. These patient barriers to diabetes care might include occupational stress or situational depression.
DQIP was formed to develop minimal guidelines for measurable outcomes of diabetes mellitus. I believe DQIP was very sincere in the quest to improve the outcomes of diabetes, namely decrease the chronic complications rates of diabetes. The complications of diabetes mellitus are heart disease, eye disease, kidney disease and neurological disease. It is true that controlling ones blood sugar will prevent or slow down the onset of complications of the disease.
The HbA1c test measures the integrated three month average blood sugar. It could be the average blood sugar was a combination of blood sugars that were high and low with very few normal blood sugars. A normal HbA1c level is 5.5% or lower. With the development of national laboratories and their national data basis we can now determine the national average of HbA1c, by zip code, or by physician. The national average is 9.2%. This is a terrible HbA1c and is a good predictor of complications of diabetes mellitus. DQIP stated the standard average HbA1c should be 8.1%. The total burden quality of care (achieving HbA1c) is on the physician. The American Association of Clinical Endocrinologist (AACE) goal is 6.5% The DQIP goal was to be a wake up call to the physician to try harder. A HbA1c of 8.1% is high value. The onset of complications of diabetes mellitus will be significant at 8.1%. Therefore the standards published are for educational purposes in my view. These standards are inadequate and will not decrease the complication rate or the cost of care.
Physicians’ agenda was to decrease the complications of diabetes by increasing awareness of the need for intensive self-management. Others in DQIP had other agendas. Some wanted to increase their funding from whoever would fund a project. Some just wanted to get the benefit of the consensus of intellectual property after compromises were made. Others wanted to sell more drugs or medical devices.
The agenda of all the stakeholders should have been to create a system that could create a competitive environment for excellent care among physicians without punitive consequences. The punitive consequences should come from the consumer driven market place. The only punitive consequence should come from the demand by their patients to help them get their HbA1c down to normal. If their physician could not help them they should be empowered to know the physician that could.
This did not happen. Instead a system of minimal quality care measurements was created. If they were not met by the physician then his P4P would be decreased by the government and the insurance industry. The quality measurements that DQIP created to help improve the quality of care delivered turned out to be a stick to beat physicians. The responsibility of the patient to improved quality of care is not taken into account. Only the physician and his healthcare team with the patient being the most important member of the team will increase the quality of medical care delivered and not the faulty incentive of P4P.