Fellow blogger DB’s Medical Rants has an interesting take on pay for performance. Citing a study published in the New England Journal of Medicine, the post notes:
“One underlying principle of the pay for performance movement stems from the belief that we can use incentives to improve adherence to evidence based quality indicators. The crux of evidence based medicine (EBM) follows from an examination of high quality data. EBM eschews belief.
This study tries to understand how P4P might influence physician practice. It finds no positive impact. Rather P4P may simply be a scheme for rewarding high performers…
However, as I hear the debate, most proponents see P4P as a means to improve quality. This article argues against that.”
Changing physician behavior is a windmill that has absorbed billions of dollars and millions of hours of tilting, with little evidence of impact. While the objective is noble, the business case is highly suspect.
What does this mean for you?
Identify the best performing physicians and direct your patients to them. Let others shatter their lances.
Oct
14
I’m suspicious of the source of the study. It is, after all, the AMA, the most vigorous opponent of P4P.
That said, we must acknowledge that all the non-doctors in the world would like to believe that the bell-curve of physician quality looks more like a shark fin, with more doctors at the high-quality end of the scale, and very few at the low-quality end. Truth is, that’s not likely (we can’t say for sure; more on that later). Like every other human endeavor, achievement of quality among physicians is likely still a bell-curve. Until we can figure a way to get human beings out of the delivery of medical care (impossible, obviously), it will always be a bell-curve. It’s unrealistic to lament the fact that we can’t make a shark fin out of it. All we can do, and what we should do, is endeavor to make that bell curve taller and narrower, and shift the whole thing to the higher end of the quality scale.
P4P remains in its infancy, but that shouldn’t be. The concept of using evidence-based guidelines to measure quality (and, by extension, employing monetary rewards to improve it) has been around for long enough that every specialty should have them by now. But they don’t. It’s nothing short of negligence that the following specialties have yet to produce evidence-based, best-practice guidelines: dermatology, gastroenterology, infectious disease, neonatology, nuclear medicine, ophthalmology (!?!?), otolaryngology, pediatrics (!?!?), plastic surgery, rehab medicine, therapeutic radiology, urology and vascular surgery.
Instead of trying to cook up some numbers to defend its position of resistence to P4P, the AMA ought to be demanding results; you know, real leadership. It ought to be giving deadlines to the various specialty societies to produce their evidence-based standards. And shame on those specialties for their lack of leadership in setting those standards themselves.
There might, in fact, be a business case to be made for P4P. Perhaps it is more effective in some specialties than others. Right now, we can’t know, and lack of leadership is keeping us from finding out.