Letters

From the January-February ACP Observer, copyright © 2006 by the American College of Physicians.

Pay for performance

I read with interest your article on the problems internists have meeting guideline targets for patients with multiple chronic diseases. ("Study finds generation gap in guidelines," December 2005 ACP Observer.)

I recently reviewed the medications required to follow authoritative guidelines for 10 elderly patients, age 67-88. Each had between one and six chronic illnesses (the median number was four).

The average wholesale cost of drugs for each ranged from $108 per month to $433 per month, with a median monthly cost of $167. Atorvastatin for hypercholesterolemia alone costs $108 a month or $216 a month for a couple. Right now, $216 is more than 16% of the monthly cash income of one-third of elderly households.

Physicians treating patients who cannot afford this expense will be penalized if published performance standards are implemented--and if doctors decide the clinical value of statins is not worth the high cost to some patients and do not prescribe them.

Arguing that this consideration should be documented in the medical record does not change the checklist aspect of pay for performance. It also does not make it more desirable to conscientiously treat low-income elderly patients, given the Medicare fee schedule for cognitive services.

Marcus M. Reidenberg, FACP
New York

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