Why does Pay for Performance (P4P) make most physicians reach for Maalox? I have devoted a good portion of this blog’s real estate to dismantling the fallacy that pay for performance improves medical quality. It’s easier to argue that this clumsy and robotic approach diminishes medical quality by incentivizing physicians and hospitals to game the system to maximize their quality scores.
When an irritating high school student raises his hand and annoys the teacher with the inquiry, ‘Is this gonna be on the test?’, it is a forerunner of the concept of pay for performance. The Ivy League seeking student won’t study material that he knows won’t appear on the exam. Similarly, physicians and medical institutions will focus their attentions on achieving those outcomes that will be measured and graded, which might be at the expense of patients who ‘are not on the exam.’ For example, if irritable bowel syndrome isn’t being measured, but GERD is, then will these patients be treated the same? Beyond this, I reject the concept that medical quality can be reliably measured and quantified.
There’s a Renaissance painting hanging on a museum wall. Is it a masterpiece? Since it’s tough to measure and judge art, should we use a ruler to measure the perimeter of the frame and consider this to be a quality surrogate? Absurd, yes. But, if you buy into this fantasy, it makes it a lot easier to measure quality.
Why shouldn’t we apply the P4P concept into other professions. Not surprisingly, folks won’t speak out against pay for performance until they are sagging under its yoke. Consider the following P4P extensions:
- Teachers’quality is judged bystudents’ attendance
- Musicians’ qualityis graded by ticket sales
- Congressmen’s quality depends upon approval ratings
- Meal quality depends upon weight
- Book quality depends upon # pages
This is the same silliness that is being imposed on the medical profession. Sure, they can present P4P to the public as rational policy, but no slogan can sanitize the scheme. Of course, serious reforms in the health care system are needed, including a hard look at how physicians and hospitals are reimbursed. Too often, the interests of the medical community and those we serve are misaligned. However, to force P4P on us and then use the results to reward or punish us financially is capricious, unreasonable and fallacious. Perhaps, even the government knows this is not a true quality initiative, but a poorly disguised cost control cudgel.
Is this blog post any good? How can we grade it? By the number of comments? Number of retweets? Why agonize. Let’s all agree that a blog post’s quality can be measured by the word count. Here’s my suggested metric.
# Words Quality
1 – 100 Poor
101- 199 Mediocre
200 ’ 300 Lousy
301-400 Below average
>400 Superb
If the Gettysburg Address is graded using the above schema, wewould seehow overrated this speech is. The reason we have elevated this speech into the pantheon of American rhetoric is because we didn’t have an available grading tool that would have shown us that Lincoln’s remarks were ordinary political drivel. Some presidents have all the luck.
Let us hope that Pay for Performance shall perish from the earth. It is altogether fitting and proper that we do this.
By Michael Kirsch, MD
Michael Kirsch, MD, is a full time practicing physician and writer. He writes regularly at MD Whistleblower about the joys and challenges of medical practice including controversies in the doctor-patient relationship, medical ethics and measuring medical quality.Visit website | More posts by Author
My father was in the ER for stomach (not chest) pain. All the docs wanted to check was his heart. They kept him for days, he was in agony...he kept telling them where the pain was (his liver/gallbladder region) and NO ONE listened. Gallbladder issues--such a common thing these days--why wouldn't anyone have thought of it?
Since the doctors get paid no matter how poorly they perform, why even listen to the patient? This was gross negligence on a scale I'd never have dreamt possible.
He was discharged without any real resolution. The pain finally stopped after 3 days without giving him any real assistance. They referred him to another doctor who finally quit messing around and listened to him. Once his gallbladder was removed, the bill for everything was over $100,000. Insurance refused to pay. (Surprised?) Had the doctors listened, it would have been less than half the expense.
So you think everything should remain as-is?
The author is rather upset at the P4P plan, but it's rather clear that the current system is worse for the patient. Doctors really should care more for their patients than the bottom line; the real tragedy is that generally, they don't.
So Dr Kirsch is advocating making decisions without information ? There's a very specific and scientific term for that: it's called guessing. And he's advocating that the incompetent be compensated the same as the excellent ? How convenient that he advocates medicine is incomparably complex science but when metrics are applied, medicine morphs into immeasurable art.
Healthcare is the only industry that recoils at the notion of transparency, accountability, measuring performance and the concept of rewarding superior performance because, well, the truth can't be measured and the public is too dumb to understand. And, for too long our govt and providers perpetuated this myth with fee schedules that pay the same to quacks as superior doctors. In fact, ineptitude is more lucrative since errors/inefficiency are reimbursed.
100 lashes with a bundle of No. 8 sutures for you, Dr Kirsch.