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Pay for performance – more red tape without improved quality of care

We all agree that improving healthcare quality is a critical goal, but there is no real consensus on how to achieve that goal. In recent years, a “Pay for Performance” or P4P strategy has been put forth by the US government’s Center for Medicare and Medicaid Services (CMS). The gist of the strategy is to pay physicians more or less based on certain disease outcome measures of the patients they treat. So if a physician treats a large group of patients with diabetes, that physician would be paid more/office visits if, on average, those patients demonstrated lower blood sugar levels, lower cholesterol levels, and less evidence of end-organ damage on various tests.

P4P assumes that a patient’s chronic disease outcomes are completely dependent upon the physician. To me, this underlying assumption (that the patient is not involved in his/her own health) is offensive. It is offensive because it assumes that patients are not in control of their lifestyle choices, that their circumstances can be summed up by lab tests, and that their doctor takes all the credit for their hard work to control their disease. It also assumes that patients and families need not be partners in the quest for optimum health – no, that is solely the responsibility of the physician. Ultimately, P4P is disrespectful to patients – it takes them out of the health equation, it presumes that they’re passive participants, and it depersonalizes medicine.

And it gets worse. If physicians are paid more for patients who do well, they will be tempted to “cherry pick” the most motivated and privileged patients. How does this help the patients who need the most help? It will further earmark them for lower quality care.

One of my favorite bloggers, Dr. Richard Reece, echoes my sentiments, further explaining how ludicrous it is to assume that doctors are in full control of patient health outcomes:

People spend 99.9 percent of their time outside of doctors’ offices and hospitals. This time gap is particularly important in patients with chronic disease. Your outcomes depend on how and where you live and work…

Many patients don’t follow doctors’ orders. Many never fill prescriptions, fail to get refills and avoid exercise.

Half-way technologies–stents, coronary bypasses, joint replacements, statins, etc.–don’t eliminate underlying diseases or change their basic pathophysiology. The problem here, of course, is many patients have overblown expectations at what these technologies will accomplish and often return to the behavior that led to the problem in the first place.

Even CMS recognizes the limitations of P4P:

Pay-for-performance is in its early stages of development and a great deal of work still must be done to determine the best method of approaching a comprehensive program.

But that doesn’t stop them from promoting the program to states that are in desperate need of federal funds:

CMS will provide technical assistance to those states that voluntarily elect to implement pay-for-performance programs. We also plan to work with states to encourage that evolving pay-for-performance programs include an evaluation component to provide evidence of the effectiveness of this methodology.

For some further examples of how P4P doesn’t work, check out the following blogs: 1) disaster in the nursing home setting and 2) a summary of recent research studies on the ineffectiveness of P4P by Dr. Poses (via KevinMD).

Then what is the real issue that we’re trying to get at?

Quality care is dependent upon the regular application of evidence-based medicine (EBM) to clinical situations. What is EBM? Every medical decision that physicians make should have a good reason behind it – and that reason, whenever possible, should be based upon scientific evidence that the decision has worked in the past. What I mean is that we spend billions of dollars on medical research to learn the difference between truth and error, and doctors should do their level best to apply the research findings to the care decisions they make each day. Now, keep in mind that there are about 6000 research articles published each day in the medical journals world-wide… so it may come as no surprise that (as Dr. Reece explains):

It’s well-documented doctors only follow preventive and treatment guidelines 50 percent to 55 percent of the time. Moreover, doctors could do a much better job communicating with and educating patients, deploying the Internet (for example) to reach patients when they are outside of the immediate care setting.

So what we really need to do, is support physician education efforts to incorporate the very best research findings into their clinical practice of medicine. How can a physician keep up with all the latest research? I maintain that the government’s efforts would be better spent on hiring physician task forces (to summarize the very latest evidence for the treatment of every disease and condition – and then supply simplified guidelines to docs across the country) than on scheming up ways to penalize physicians for treating patients who are sicker and less willing or able to take control of their health. It would be great if physicians were incentivized to use the latest clinical guidelines in their care of patients – but basing the incentives on outcomes (rather than on applying the guidelines) cuts out the patient’s responsibility as a partner in the treatment. As Dr. Feld rightly points out, quality care based on EBM could be vastly improved through a central EMR.

And what can patients do?

In this new era of consumer directed healthcare, patients need to understand that they really are co-partners with their doctors. A doctor can give you all the best possible advice, but if you don’t take the advice, then that doctor’s work on your behalf may be in vain. I believe that patients should be aware of the care guidelines that doctors use to treat them – and have access to a simple check list to track their own progress. I am personally helping to translate clinical guidelines into consumer-friendly lists for patients so that they can actively participate in, and follow along with, their care plan (so stay tuned for that). Revolution Health is committed to empowering consumers – and helping them to be a full partner on the road to wellness. In fact, we are developing a full suite of su
pportive services (including health coaches, chronic disease management programs, insurance advocates, nurse call lines, physicians available via email, and more) that will make it much easier for them to stay on track. In addition, we are enabling physicians to customize educational information for their patients, and participate (via IT) in a broader relationship with them.

There are many exciting improvements in healthcare currently under development. The Internet will play a central role in connecting patients and physicians to the scientific information that will help them get the best care no matter where they are or which doctor they see. I don’t believe that P4P is anything more than another misguided attempt to “improve healthcare quality” by creating more of the red tape that keeps doctors and patients from meaningful personal interactions.

This post originally appeared on Dr. Val’s blog at

Speed & quality: are they inversely proportional in medicine?

In my last post I described a form of short hand that we docs use to communicate. One of my readers sent me a personal note via email. I thought she made some excellent points, so I’m going to post them here (with the silent conversation going on in my head when I read it typed conveniently in ALL CAPS).

The modern day pace is so incredibly stepped-up nowadays that it makes me nervous about human error. YOU SHOULD BE AFRAID. When doctors don’t have time to write complete words on paper, do they have time to give your case enough thought?  PROBABLY NOT. Will some important detail slip past them?  SURE. Will they make a mistake because they misread one of those code letters? NO, I DON’T THINK SO, THERE ARE PLENTY OF BETTER WAYS TO MAKE MISTAKES, LIKE GRABBING THE WRONG CHART.  I should think that would be easy to do when doctors have terrible handwriting due mainly to haste. DON’T KID YOURSELF, THEIR HANDWRITING LOOKS EXACTLY THE SAME WHEN THEY HAVE ALL THE TIME IN THE WORLD.

All jest aside, we are in a serious quandary here… the poor primary care physicians in this country are totally swamped, they are under extreme pressure to see more patients in a day than should be legal, and in the end the patients suffer. At a certain tipping point (let’s say 12 patients/day) speed really does become inversely proportional to quality.

Instead of developing complex pay for performance measures, why not find ways to incentivize docs to see fewer patients? Truly, quality would automatically improve, patients would learn more about how to manage their chronic diseases, and docs would be happier and more productive. The quality police fail to recognize that time is the key to improving care. Can we really afford to keep up this frantic pace?

This post originally appeared on Dr. Val’s blog at

The dark side of measuring healthcare quality?

Improving quality in healthcare is an important fundamental goal. New “pay for performance” measures initiated by the Center for Medicare and Medicaid services is a well meaning attempt to provide financial incentives to physicians who demonstrate improved patient outcomes. Unfortunately, this incentive program could backfire.

A recent article in Medical Economics (via Kevin MD) raised the question of “cherry picking and lemon dropping” your way to higher pay. In this frightening scenario, physicians would be tempted to select healthier, more compliant patients for regular treatment in their practices. In this manner, they can demonstrate better outcomes, since the sicker, poorer, or less compliant patients no longer factor into their performance measures. And with the upcoming physician shortage, it really is a seller’s market.

It is critically important for the government programs to allow physicians to accurately risk stratify their patients so that they are not financially penalized for taking care of sicker patients bound to have below average outcomes. The same goes for surgeons, who should not be discouraged from undertaking potentially lifesaving surgeries for patients who are critically ill.

Dr. Kellerman, the president of the American Academy of Family Physicians, reminds us that quality of care is vastly improved by having a central medical home (i.e. one physician who can coordinate care for patients, so they’re not left with a group of disconnected specialists ordering duplicate tests and prescriptions). I personally think that a centralized EMR/PHR controlled by the patient (and located at an Internet based “medical home” complete with disease management tools and the ability to email a physician as needed) would go a long way to improving quality.

What do you think?

This post originally appeared on Dr. Val’s blog at

Medical errors may be reduced by redundancy?

One of the great advantages of electronic medical records (EMRs) is that they can reduce unnecessary repeat testing. Without an EMR that is accessible to all physicians taking care of a single patient, there’s no way for them to know what the other one is prescribing. Expensive tests like MRIs are often ordered by two different physicians (a neurosurgeon and a rehabilitation medicine specialist for example) because one didn’t know that the other had already ordered it. Alternatively, they may be affiliated with institutions that don’t share data, so previous MRI images are not available for viewing by the new specialist – so she just orders another one.

However, an interesting question is raised by Dr. Perloe’s post to my last blog entry: what if all specialists taking care of a patient had access to one medical record – and there was a lab error? They would all rely on the same erroneous record, and this could spark a whole host of inappropriate tests and procedures. Even second opinions (based on one single record) would be less helpful – because they would be misled by false results.

So, the irony is that the redundancy in our system has its benefits. We should be mindful of the checks and balances that we are unwittingly removing with EMRs. Occasional lab errors will always be with us – let’s make sure we catch them early, and not commit them to a permanent record relied upon by all.

This post originally appeared on Dr. Val’s blog at

Medical errors – apologies required

Our Chief Privacy Officer sent me an interesting article today about how hospitals are promoting “disclosure and apology” (by physicians to patients or their families) when a medical error is committed.  The report suggests that less money will be spent in malpractice suits if physicians fess up to their mistakes instead of trying to hide them.

Another study suggests that 99% of physicians believe that it is morally right to confess errors to patients and family members, but that only about 33% report doing so.  The article says that the number one reason why they don’t report errors is fear of being sued.

While these statistics don’t reflect well on physicians, I think there’s some murkiness here that’s worth reviewing.  First of all, what constitutes an error?  When a young resident physician performs a procedure in an inferior manner due to lack of experience, is that an error?  When a code team is not called soon enough because a patient doesn’t appear gravely ill initially, is that an error?  If an unconscious patient arrives in the ER and is treated with a medicine that causes a life-threatening allergic reaction, is that an error?  I think that many times physicians perceive some “errors” as unfortunate and regrettable aspects of the natural practice of medicine and don’t report them formally.

Another reason why physicians may not report errors is because it’s unclear that the error has a specific adverse effect – perhaps a patient’s Tylenol was given at the wrong time of day.  That’s an error – but is it worthy of formally reporting it to the patient?  What about when the lab loses the tube of blood drawn from a patient?  Should the patient be told about it or should the labs be added to the next day’s scheduled draw?

The majority of “errors” that I’ve witnessed are in the realm of sub-optimal care due to inexperience, inattentiveness, or misinterpretation of test results.  However, errors of the sort that result in death and serious harm appear to be alarmingly frequent (some studies argue that there are 40-90 thousand of these errors per year).

I think that physicians should always tell patients the truth about their care, the risks associated with certain procedures, and the full range of choices that are available to them.  I do believe that patients value (and deserve) to know the truth – even when it makes the physician or hospital seem less than perfect.  In the cases of errors that result in serious consequences – honesty is the best (and only) policy.This post originally appeared on Dr. Val’s blog at

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