American College of Physicians: Internal Medicine — Doctors for Adults ®


Doctors debate P4P, address impact on primary care

Patient-centered medical home topped agenda of the more than 300 internists who converged on Capitol Hill

From the July-August ACP Observer, copyright 2007 by the American College of Physicians.

By Deborah Gesensway

TORONTO—Debate about the theory and practice of pay-for-performance (P4P) topped the agenda at this spring's annual meeting of the Society of General Internal Medicine (SGIM). While debate centered on how P4P programs can be implemented fairly for physicians and patients, some physicians questioned whether they should have bought into the concept in the first place.

"I fear that we as primary care providers have boxed ourselves into a corner," said Nicole Lurie, MACP, former SGIM president and current director of the RAND Center for Population Health and Health Disparities, during the April meeting's keynote address. "We are doing a better job following the guidelines and checking the boxes," as reflected in the improvements in standardizing processes of care as gauged by the first batches of quality measurements, "but outcomes are not improving."

A major concern about paying doctors for their performance, she said, is that its incentives "may push us to abandon our ideals," particularly by encouraging physicians to cherry-pick the patients that will ensure they meet the targets being measured.

In the United Kingdom, for instance, researchers found that the national P4P program introduced in 2004 motivated general practitioners to improve care by making better use of previously underused information technology and multidisciplinary teams. Bruce Guthrie, MB BChir, PhD, of the University of Dundee, in Dundee, Scotland, who presented a study on the U.K. program, said general practitioners worried about two negative consequences of P4P:

Tunnel vision: Concentrating on the conditions eligible for incentives means less time for patients with conditions that were not being measured by the program, such as depression.

Crowding out: Reducing or eliminating primary care services without specific reimbursement, such as travel medicine.

A featured debate at the meeting, had two top internists squaring off on the topic of physician profiling, accountability and pay for performance. Thomas H. Lee, ACP Member, Network President of Partners HealthCare System in Boston, argued that ever increasing costs of health care mandate immediate actions to improve quality and efficiency, and that, for organized providers, P4Pis the most attractive option on the table. Rodney A. Hayward, ACP Member, professor of internal medicine at the University of Michigan, took the other side, contending that physician-level profiling will neither lower costs of healthcare nor reduce inefficiencies in the system.

"How much can a doctor improve by doing what you want and how much by doing what you don't want them to do?" Dr. Hayward asked. "It's easier to improve my score by getting rid of one to three high-cost patients than by changing my practice for all. Deselecting high-cost patients is easier than improving care."

Moreover, he said, variation noted among individual physicians is due more to patient and chance variability than to physician variability, he said. "We have been saying [quality] is a systems issue, but now we're saying, we have to look at the individual doctor." It's like judging the quality of a product produced at one factory by the individual assembly line worker and not by the factory as a whole, he said.

Although he would agree that paying for performance on a systems level, rather than an individual physician level, makes more sense, Dr. Lee said, it is also true that systems, such as an integrated provider organization, start with individuals. "At the end of the day, we need physicians to do the right thing."

In addition, he said, the measurements that P4P programs are using have improved. Instead of paying for process measures such as obtaining annual hemoglobin A1c levels for diabetic patients, the next level of P4P includes measures that are more outcomes-oriented, such as patients' hemoglobin A1cs that are below 7%.

In Dr. Hayward's opinion, however, these new measures are just as flawed as the old ones—and maybe even worse, because they are bad measures of quality. For instance, there is no good evidence that all hemoglobin A1c levels must be below 7%. And, he said, concerning blood pressure measures, pushing patients to reduce blood pressure from 140 mm Hg to 130 mm Hg can do more harm than good for some patients.

"You can't have simplistic measures and think you are measuring quality," Dr. Hayward said. "The measures don't reflect the reality that you have to tailor treatments to individual patients."

Dr. Lee said he also favors trying to make P4P work because other choices for how to rein in out-of-control health care spending—namely, prior authorization programs, tiered networks and more cost-shifting to consumers—are worse.

"Cost and inefficiency are important," agreed Dr. Hayward, adding, "but they have nothing to do with physician P4P."

While physician-level P4P alone will probably not save money, Dr. Lee said, it should make physicians more efficient by strongly encouraging them to adopt electronic medical records, multidisciplinary teams and other mechanisms that over time will reform the healthcare system. "The goal is to provide tools to stop clinical inertia."


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