Healthcare costs in the US have been climbing at scary rates. Many ideas have been created and tossed about to help curb these costs. One of these proposals is pay-for-performance, where the physician or other medical entity is paid based on patient outcomes. While we all strive for high quality medical care for patients, I find several drawbacks to this model of payment.
1. Physicians Are Already trying to Give Their Patients the Best Care.
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By rolling out P4P reimbursements, the implication is there that doctors don’t already strive to give their patients the best. The underlying message is that by providing financial incentives, doctors will be incentivized to give their patients better medical care. I think this only further drives a distrust between patients and physicians. If a patient does not trust that I have their best interests in mind when I am treating them, I have failed them as a doctor. The doctor-patient relationship is one of the most important aspects of medical treatment.
2. Patients Frequently Don’t Follow Their Doctor’s Advice.
As a doctor who treats many chronic medical conditions, I always give advice to my patients regarding healthy lifestyles including diet and exercise. I talk to them about the importance of taking their medications every day and what can happen if they miss doses. I spend a great deal of time counseling my patients about healthy behaviors. Yet, I cannot force my patients to follow my advice. Many doctors feel that P4P is unfairly punitive for their patient’s bad choices.
3. Who is Setting P4P standards?
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Another concern among doctors is who is determining the P4P metrics? It seems many times that these measures are being decided by non-physicians. Government and private insurers are looking at outcomes that decrease cost to them and the healthcare system in general. Physicians try to control costs, but we are still responsible for providing the best medical care to our patients. There are times when cost of medical care comes secondary to giving our patients the best medical care possible. Cost-effective medicine is not always synonymous with quality care. When administrators are tasked with determining P4P metrics, they are not considering individual patient’s well-being. They are looking at cost as a total. Standardizing these metrics may work generally, but individual patients may fall through the cracks when these outcome measures are strictly enforced.
4. Patient Demographics May Be Unfair to Providers in Certain Geographic Areas.
I have often found that patients are more likely to follow my advice based on educational level. This is not strictly true. If a doctor practices in a more inner city area with more disadvantaged populations, they may get less to adhere to their medical advice. They are therefore at a disadvantage in the P4P model. These medical providers stand to get penalized for treating patients that other doctors don’t necessarily want to treat. Over time, I feel under the P4P model, these patient populations will have an increasingly difficult time finding doctors to treat them.
5. P4P costs Healthcare Dollars in its Implementation.
In order to carry out such a system, a great deal of money needs to be invested. New people need to be hired and trained to do this job. Software needs to be developed and monitored in order to carry out tracking of the metrics. Perhaps these dollars could be better spent on other ways of improving patient care than implementing a system to essentially police doctors.
P4P is having an increasing role in our healthcare reimbursement system. Whether it truly will control costs remains to be seen. But, with its implementation, it needs to be carefully evaluated whether it truly does improve patient care or just cut costs. Additionally, it needs to be implemented in a way that does not unfairly punish doctors for doing their job.
