January 29th, 2011 by KevinMD in Health Policy, Opinion
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I recently pointed to a BMJ study concluding that pay for performance doesn’t seem to motivate doctors. It has been picking up steam in major media with TIME, for instance, saying: “Money isn’t everything, even to doctors.”
So much is riding on the concept of pay for performance, that it’s hard to fathom what other options there are should it fail. And there’s mounting evidence that it will.
Dr. Aaron Carroll, a pediatrician at the University of Indiana, and regular contributor to KevinMD.com, ponders the options. First he comments on why the performance incentives in the NHS failed:
Perhaps the doctors were already improving without the program. If that’s the case, though, then you don’t need economic incentives. It’s possible the incentives were too low. But I don’t think many will propose more than a 25 percent bonus. It’s also possible that the benchmarks which define success were too low and therefore didn’t improve outcomes. There’s no scientific reason to think that the recommendations weren’t appropriate, however. More likely, it’s what I’ve said before. Changing physician behavior is hard.
So if money can’t motivate doctors, what’s next? Physicians aren’t going to like what Dr. Carroll has to say. Read more »
*This blog post was originally published at KevinMD.com*
March 19th, 2010 by EvanFalchukJD in Better Health Network, Health Policy, Opinion
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The Jobbing Doctor, a primary care doctor in the UK, writes about the British version of what Americans call “Pay for Performance,” or “P4P.”
He says something I’ve said many times before (like here, here, and here). Which is this: incentives fail because they try to treat medicine as an assembly line process, when it’s not.
But what’s most interesting about his post is that it could have been written by a doctor from anyplace on the planet Earth.
The Jobbing Doctor talks about a UK program that started in 2004 called the Quality and Outcomes Framework, or “QoF.” Now, the American “P4P” is a much more catchy name, so score one for American marketing. But it doesn’t matter what you call it – that which we call a rose would, by any other name smell as sweet. Read more »
*This blog post was originally published at See First Blog*
December 2nd, 2009 by Happy Hospitalist in Better Health Network, Health Policy, Opinion, True Stories
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It’s official. Happy has now earned his CMS physician pay for performance PQRI Bonus for 2008, a direct deposit into Happy’s bank account. PQRI stands for Physician Quality Reporting Initiative. How much was my PQRI Medicare pay for performance bonus for calendar year 2008? A $2,500 check written out directly to Happy by the Medicare National Bank. CMS gives a wonderful overview of the history of PQRI . PQRI is the Medicare pay for performance program for physicians that was initiated by Congressional mandate in the latter half of 2007. Doctors have an opportunity to earn back 2% of their gross Medicare collections (which the government calls a bonus but which I call legalized theft) by submitting a grotesque amount of quality performance paper work to the Medicare National Bank. It’s one giant PQRI guideline game.
PQRI reporting is currently voluntary, but legislation in future years will certainly mandate reductions in payment for not submitting data, all but making this program a punitive standard. Many physicians failed to meet the requirements to get paid under CMS pay for performance program guidelines in the latter half of 2007, the first year for PQRI measures. Read more »
*This blog post was originally published at The Happy Hospitalist Blog*
October 28th, 2009 by SteveSimmonsMD in Primary Care Wednesdays
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Over 25 years ago I witnessed a crime, committed by my family doctor. I was waiting to pay for my visit when an elderly, dignified, but obviously poor woman pulled out her checkbook, clicked open her pen, and asked, “How much do I owe?”
The receptionist’s answer piqued my interest and admiration, “The doctor said no charge, we’ll just bill your insurance.” I still remember the gratitude conveyed by her body language as she said, “Thank him for me,” returned her checkbook to her purse and left. Naïve to the complexity involved in medical billing, I was unaware that anything wrong had been done and did not resent having to pay for my office visit since our family could afford to pay; however, he eventually served time in jail for what I have always considered crimes of compassion. Perhaps I lack the details of his legal case to properly consider his actions but I’ll never forget the respect shown him by my home town in rural Tennessee after his time had been served; my family among many he continued to care for. Read more »
November 8th, 2008 by Dr. Val Jones in Celebrity Interviews, Expert Interviews
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Dr. Gawande
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Kaiser Permanente sponsored a special event in DC today – Charlie Rose interviewed Dr. Atul Gawande about patient safety in front of an audience of physicians. Dr. Gawande is a young surgeon at Harvard’s Dana Farber Cancer Institute, has written two books about performance improvement, and is a regular contributor to the New Yorker magazine. I had heard many positive things about Atul, but had never met him in person. I was pleasantly impressed.
Atul strikes me as a genuinely humble person. He shifted uncomfortably in his chair as Charlie Rose cited a long list of his impressive accomplishments, including writing for the New Yorker. Atul responded:
I’m not sure how my writing became so popular. I took one fiction-writing class in college because I liked a girl who was taking the class. I got a “C” in the class but married the girl.
He went on to explain that because his son was born with a heart defect (absent aortic arch) he knew what it felt like to be on the patient side of the surgical conversation. He told the audience that at times he felt uncomfortable knowing which surgeons would be operating on his son, because he had trained with them as a resident, and remembered their peer antics.
Atul explained that patient safety is becoming a more and more complicated proposition as science continues to uncover additional treatment options.
If you had a heart attack in the 1950’s, you’d be given some morphine and put on bed rest. If you survived 6 weeks it was a miracle. Today not only do we have 10 different ways to prevent heart attacks, but we have many different treatment options, including stents, clot busters, heart surgery, and medical management. The degree of challenge in applying the ultimate best treatment option for any particular patient is becoming difficult. This puts us at risk for “failures” that didn’t exist in the past.
In an environment of increasing healthcare complexity, how do physicians make sure that care is as safe as possible? Atul suggests that we need to go back to basics. Simple checklists have demonstrated incredible value in reducing central line infections and surgical error rates. He cited a checklist initiative started by Dr. Peter Pronovost that resulted in reduction of central line infections of 33%. This did not require investment in advanced antibacterial technology, and it cost almost nothing to implement.
Atul argued that death rates from roadside bombs decreased from 25% (in the Gulf War) to 10% (in the Iraq war) primarily because of the implementation of check lists. Military personnel were not regularly wearing their Kevlar vests until it was mandated and enforced. This one change in process has saved countless lives, with little increase in cost and no new technology.
I asked Atul if he believed that (beyond check lists) pay for performance (P4P) measures would be useful in improving quality of care. He responded that he had not been terribly impressed with the improvements in outcomes from P4P initiatives in the area of congestive heart failure. He said that because there are over 13,000 different diseases and conditions, it would be incredibly difficult to apply P4P to each of those. He said that most providers would find a way to meet the targets – and that overall P4P just lowers the bar for care.
Non-punitive measures such as check lists and applying what we already know will go a lot farther than P4P in improving patient safety and quality of care.
Atul also touted the importance of transparency in improving patient safety and quality (I could imagine my friend Paul Levy cheering in the background). In the most touching moment of the interview, Atul reflected:
As a surgeon I have a 3% error rate. In other words, every year my work harms about 10-12 patients more than it helps. In about half of those cases I know that I could have done something differently. I remember the names of every patient I killed or permanently disabled. It drives me to try harder to reduce errors and strive for perfection.
Atul argued that hospitals’ resistance to transparency is not primarily driven by a fear of lawsuits, but by a fear of the implications of transparency. If errors are found and publicized, then that means you have to change processes to make sure they don’t happen again. Therein lies the real challenge: knowing what to do and how to act on safety violations is not always easy.
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Charlie Rose
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Charlie Rose asked Atul the million dollar question at the end of the interview, “How do we fix healthcare?” His response was well-reasoned:
First we must accept that any attempt to fix healthcare will fail. That’s why I believe that we should try implementing Obama’s plan in a narrow segment of the population, say for children under 18, or for laid off autoworkers, or for veterans returning from Iraq. We must apply universal coverage to this subgroup and then watch how it fails. We can then learn from the mistakes and improve the system before applying it to America as a whole. There is no perfect, 2000 page healthcare solution for America. I learned that when I was working with Hillary Clinton in 1992. Instead of trying to fix our system all at once, we should start small and start now. That’s the best way to learn from our mistakes.
