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I Hit A Nerve With My Criticism Of Pay for Performance (P4P)

Stanley Feld M.D.,FACP,MACE

I hit a nerve with my criticism of P4P. The reaction came from healthcare professionals who have worked hard to help organizations generate guidelines to improve the quality of care. They recognize that the healthcare system is in trouble. They all are sincere in wanting to help fix the dysfunctional system. You may recall I said everyone is to blame for the dysfunctional healthcare system. Government, insurance companies, hospitals, patients, and pharmaceutical companies as well as physicians are at fault. The healthcare system has to be repaired before it implodes.

In 1984, the government was certain that the DRG system for hospital reimbursement would control the escalating hospital costs. The defects in the DRG system made DRGs ineffective in controlling hospital costs. The result was escalating hospital costs rather than decreasing costs.

Intuitively, P4P is system that sounds like it should work. However, P4P does not include the entire meaning of the evaluation of quality of care. It is a good idea to develop criteria to judge effective treatment. However, who is the judge of effective treatment? Does anyone have the power to judge the judge? Both the physicians and the patients are responsible for the effective treatment outcomes. Patients must understand their responsibility in the outcomes of treatment. If they do not comply, the treatment will be ineffective. If the physicians are not reimbursed for developing education centers and a team approach to the treatment of chronic disease in order to help the patients become the professor of their disease, they are unlikely to develop that resource necessary for the treatment of chronic disease. The approach to treatment for chronic diseases must be a team approach with the patient at the center of the team. Physicians can not afford to set up the educational facility if they are not reimbursed for the service. Hospitals have opened and subsequently closed chronic disease education centers. They can not afford to keep them open. Who is at fault? Is it the physician, the patient, the government, the hospital or the insurance company? Who should bear the burden of proof of performance be on?

It is generally accepted that most of the money spent in the healthcare system is on treating the complications of chronic disease. Physicians are great at fixing things that are broken. We have not done very well at preventing disease or treating chronic diseases according to the Institute of Medicine. Why is there no compensation for this important skill set?

We know obesity is a risk factor for many chronic diseases such as heart disease and diabetes. Yet we continue to gain weight and increase the chances for the complications of these diseases. Who is responsible for this obesity epidemic? Is it the patients, the physicians, the government or our farm subsidies?

Patients are frustrated by the difficulty in negotiating with the healthcare system stakeholders. It is claimed that it is nearing impossible to speak to a physician on the telephone. There are stories of long waits for appointments to see physicians. Once the appointment is made there are long waiting room waits. It is difficult to coordinate tests in a timely manner. The work up is often attenuated when diagnosis should be made promptly and treatment should start quickly. The problem coordinating schedules with the various medical services is becoming more difficult. The segmentation of diagnostic workup and delays in getting workups completed have created increased distrust for physicians and eroded their therapeutic effectiveness. The physician patient relationship, an important aspect of therapeutic effectiveness is undermined. Whose fault is that and how does it get fixed? The answer is all the stakeholders are at fault as costs continue to escalate.

Physicians have to see more patients in a shorter time without complete workup in order to meet productivity quotas imposed by hospital systems that employ the physicians. If the physicians are in private practice, they have to see more patients in a short time in order to meet their overhead as reimbursement diminishes. They cannot afford not technologies that might improve their efficiency and lower the cost. Also, they might not have the skill set to make their practice more efficient. Electronic medical records have been an expensive false hope to many physician practices.

All the key stakeholders are frustrated. Hospital administrators claim they work hard for their million dollar plus salaries, and insurance executive claim things are tough as they go home with their two million plus salaries.

There are many things wrong with the healthcare system. P4P is not going to fix it. It is time to be honest and get serious about fixing all the defects in the healthcare system. I have outlined many of the steps necessary in my recent summaries.