Despite the challenges, P4P has potential. One model worth consideration is the P4P plan by the Bridges to Excellence organization.

The thing I'd like to see, however, is the use of performance measures for more than incentive payments. That is, we should use outcome measures to drive continuous quality improvement through the ongoing development of ever-better evidence-based practice guidelines, rather than just using process measures to assess if a particular guideline was followed.

Anyway, you say: "I am ashamed (really, I am appalled) when I see the total lack of understanding these physicians have regarding the way things really are in health care."

I wonder what accounts for such ignorance among practitioners about the realities of healthcare today. Any ideas? What can be done increase their knowledge?

Steve Beller, Ph.D.
http://curinghealthcare.blogspot.com

I'm not so sure how you are going to measure quality.  Steve mentions focusing on outcomes, but I don't see how that can be accurately measured. 

If medicine was an exact science, and patients were identical, maybe that would work, but then we likely wouldn't need doctors. We could simply out source everything to technicians, who could just read from a manual, and decide on the best course of action. 

But we're not all the same.  We are all different.  We are in different physical conditions, and even within the same disease, can present in different stages of progression or even less aggressive variants of the same disease.  All of which can produce different outcomes. (Take me for example.)

How do we compensate for the doctor who takes the more difficult cases, and has worse outcomes?  Is he to be penalized, and receive less pay, even though he may be the best within his field? 

I fear the population bias you talk about in your previous post, which may even result in doctors shying away from more difficult cases, in favor of patients who are younger, not very far along in disease progression, and more likely to produce better outcomes, leaving others to less qualified doctors.

The healthcare system in the US is screwed up for many reasons, and is a topic on many other blogs, but while quality provided by our health care delivery system is of primary concern for all of us, I'm not sure that P4P will have much effect in solving any of the more serious problems.

It could even be a hindrance to true health care reform, by redirecting the focus of discussion away from those efforts.

I was venting out of frustration.  It is easy for physicians to complain without having anyting new to bring to the table.  P4P addresses one of my biggest frustrations - the perverse payment system that motivates bad outcomes and the sorry state of medicine at this time.  Doctors fail to recognize that we are not doing a good job (not that we are being lazy, or not trying).  Why am I so passionate about that?  Using EMR for the past 10 years, I see what the difference in quality I can perform.  There is absolutely no way physicians not using EMR can do as good of medicine as those who do.  It is blatently obvious to me - like saying cars are faster than walking.  Your suggestion that "having an EMR does not make a good doctor a better one" shows to me that you have never seen an EMR working well in an office.  We have over half of our diabetics with an A1c under 7%.  My average LDL for diabetics is under 100.  We send letters to our diabetics who are missing care - those who have not had an A1c in the past 6 mos and don't have an appointment.  I do Framingham risk evaluations on every hypertensive, hyperlipemic, and every diabetic patient in my practice.  The patients know their 10 year risk of dying from heart disease.  I am utterly convinced that my quality of care is far higher than it once was prior to EMR.  I am not saying I am smarter.  Let me put it this way:  "Your son may run faster than my son, but my son has a car."

If you look at the numbers, the top 10% of patients for Medicare in terms of spending account for 66% of the total costs.  The burden of chronic disease (such as Diabetes and CHF) is substantially higher in that group - from 200-400% of those in the bottom 40%.  Management of those diseases has been shown to reduce cost (even with your suggestion that they would die younger and cost less - this has never been shown to be the case). 

Regarding the reduced cost for P4P - Bridges to Excellence estimates that for every dollar they invest they get back 3 dollars.  There is also evidence that doctors who qualify for Bridges to Excellence (via NCQA certification) cost half as much as doctors who do not qualify.

Physicians need to take back the management of care.  They need to take back evidence based medicine.  Don't you realize that I have far better information on my patients than the insurance companies?  They are very interested in the quality information I can generate (especially in that it far exceeds the national norms).  If I had a group of physicians improving their performance using IT and teaming up, we could do a much more efficient and higher quality job of managing care than the insurance companies and their coercive tactics.  Why do we let others make the calls?  Why do we resist change when change would actually put the key to the city in our hands? 

Regarding my scoff at the statement: "If we got rid of those dang insurance companies, healthcare would be a bargain (yes, someone actually said that)."  I think this is just a dumb thing to say.  Of course insurance companies add a lot to cost, but it is so simplistic to think that you would not create other problems by just getting rid of them without some way of doing things more efficiently.  Come up with a better solution (which is what I am trying to do).  My objective from day 1 has been to put them out of the managed care business.  They have no business looking over my shoulder saying how to practice medicine if I can do a better job without them.  The problem is, I have to be accountable in both the quality and cost of what I do to the consumers of health care.  Managed care came along because doctors were content with a system that mismanaged care.  Pay for performance is coming along because the performance of most physicians in quality standards is dismal.  I am trying to find a way for physicians to take the initiative to improve quality and reduce cost.  I have told our local insurance vendor that I would be willing to incorporate all of the disease management standards they use into my EMR and allow auditing to assure I kept up with those standards - In exchange, I would not have to get authorizations and, because their administrative costs would go way down, I should have an increase in pay.  They understand that this takes power away from them, so they are not interested (even though it would save them a lot of money).  I see P4P and EMR as ways for physicians to get back into the driver seat of medicine.

I am passionate about this and probably run on too much at times, but it is hard to see a solution and for your fellow physicians continue to insist that the king's clothes look great.  We must take back medicine, but to do so we must first clean up our own act.  Don't defend the current system.  Don't attack innovation without having a viable alternative.  If we let P4P just happen to us, then we will get nailed - there is no such thing as a free lunch.  But if we embrace P4P and engage ourselves and even lead in the process, we can make it into something that will potentially be the first step in taking back control of the business of medicine.

Rob
 

Augusta, GA

For other writings, check out

http://robsoddblog.blogspot.com/

Much of what you say does make sense, but I still have my doubts that quality of health care can be measured accurately. 

Sure we can measure the likelihood that someone will develop an infection during a hospital stay. We can also measure how many times instruments are left in a patient after an operation, or an operation is performed on the wrong body part, but beyond that outcomes are way to subjective to be judged accurately.

I liken it to cancer treatments.  Sure I can get a remission, by injecting deadly chemicals into my body, and/or have radiation treatments, but what are the trade offs?  Peripheral neuropathy, and/or heart damage, which can create serious quality of life issues, but I did have a good outcome, or did I?

Oh, I don't know, I probably shouldn't even be participating in this topic, because I am not a doctor or otherwise associated with the health care industry.

I have always thought of medicine much like I think of my profession as a metallurgist in the aerospace industry.  (There is even a similar comment I hear so much in medicine, "ask two metallurgist the same question, and you'll get two different responses".)

Every heat of material I deal with is different (although not as different as human beings), and sometimes requires a slight tweaking of the process to produce the desired results.  It is my 30 years of experience in this field, that has afforded me the knowledge to know what to do in each particular case.  That is how I think of my doctor.

But to minimize the amount of tweaking that I may have to do, depending on the particular type of material, or the end properties required, I will specify certain parameters for a heat of material, to improve the outcomes. In many cases I may even pre-qualify the material before using it, and if it doesn't meet that criteria, I won't use it, or I'll apply it to a less critical application. 

Now measuring my effectiveness is easy.  All you have to do is track outcomes i.e. rejection rates.  But remember I have been selective in the materials I use. 

I would hate to see medicine come to that!

Excellent discussion!

Let me see if I can tie together some of the things we’re discussing: Evidence-based practice guidelines, outcomes, improvement in care effectiveness, cost control, transparency, EMR, and P4P.

I contend that any meaningful and sustainable improvement in our broken healthcare system requires that all patients receive the most cost-effectiveness care – be it well-care (i.e., prevention), catastrophic care, and compassionate end-of-life care. This requires that (a) patients and providers know the best (most cost-effective) treatments/interventions for each particular health problem/risk, (b) providers are able and motivated to deliver that care, and (c) patients are able and motivated to comply with the plan of care.

Accomplish this requires addressing the following issues, which are all part of our Wellness-Plus Solution:

1. We have to replace ignorance (see the Knowledge Void) with a concerted collaborative effort to gain the knowledge needed to make better clinical decisions (both diagnostic and plan of care generation);

• One critical tactic is the development, dissemination, and implementation of evolving evidence-based practice guidelines (note that this link deals with Marc’s comments about the difficulty in using outcomes to evaluate performance). Implementing this tactic requires addressing several problems with current practice guidelines and quality improvement (QI) programs, which, btw, include the need for better diagnostic systems.
• Another is the use of evolving health information technology (HIT) tools. An EMR/EHR/PHR is one set of tools needed and COPE tools/functionality is another. But there are a host of other tools described in the preceding link that go much further in supporting diagnostic and treatment prescription decisions and driving an evidence-based decision support process. There several concerns about HIT and solutions.

2. Current day policies and practices, which impede providers from spending the time and having the resources to give patients the best possible care, should be changed (See Healthcare Fidelity )

3. Treatment decisions are rarely tailored to the specific needs of the individual patient taking into account the person’s age, gender, race, genetics, environment, concomitant treatments, quality of life preferences, and other factors that may be relevant to a high-quality plan of care (see Personalized Care ).

4. Increasing provider motivation to change is another issue needing resolution. This is related to the P4P issue.

5. Creating a sane payment system would certainly help. This address the issue of transparency of care cost and effectiveness.

6. Consumers should be better informed so they can distinguish among levels of quality by knowing the relative cost and degree of defect (underuse, overuse, and misuse) of healthcare resources.

7. Consumer education and wellness programs are also important.

Steve Beller, Ph.D.
http://stevebeller.curinghealthcare.com

"It costs a lot less to do a mammogram than to treat breast cancer - that has been shown clearly.  "

Do you have a reference? Because in reality this has never been shown. In fact mammograms are not cost effective at all for the reasons  below:

a) Mammograms do not prevent  breast cancer, so women still need to treat cancer with at least surgery, often with surgery+radiation, often also + tamoxifen

b) More screened women are diagnosed with breast cancer than unscreened women because of both overdiagnosis and anticipation (incidence increases with age so with screening a 40 year old sees incidence of 43 year old, etc.), so more women need to be treated. A recent article in the BMJ estimated overdiagnosis in Malmo trials at 10%, but if you read rapid responses to the article and do your own math - the authors don't seem to realize that when the denominator in the division is greater the result of smaller => their results are diluted), you'll understand that the rate is more around 30%, higher if you consider more accurate mammograms now.

c) It's been estimated that cumulative incidence rate after 10 yearly mammograms is around 50%. Doctors love to say - or it is only 10%, forgetting to say that it is after one mammogram, not after 10 years. So you need to add cost of additional mammograms for false positives

d) Some of the false positives result in biopsies, so you need to add this cost as well.

e) Different lesions grow at different rate - so in some cases, early detection will not make a difference. If a tumor is very aggressive it'll kill somebody anyway, but you'll get longer period of being sick -> higher cost. If it is very slow growing, early detection will not matter as it would be just as curable 2- and 3- years later, although you might save some money on treatment in some cases, but not in all.

Now do the math. You can take this article as reference and adjust the false positive rate for annual instead of biennial mammograms (that is if you can do math):

http://bmj.bmjjournals.com/cgi/content/full/330/7497/936

Dr Rob - do you routinely lie to your patients about benefits vs risks of mammograms?

Just wanted to add something to previous message.

One of the problems of P4P in its suggested form is that it encourages doctors to do more screening by any means without any regard for informed consent or patient's choice. Also without any real need -- a doctor who is evaluated on % of women who do pap smears will want to do them every year, even if current recommendations say that after a number of consequitive negative pap smears, they can be done less often in some cases; even on women who had hysterectomy and  have no cervix (see JAMA article on % of women with no cervix who still have pap smears), even on 70-year olds after 10 normal pap smears and no sex for 10 years. Even now very few doctors told patients they can do pap smears less often. With P4P, it'll be even worse.

Also, as a patient, I want an honest infrmation about risks/benefits of tests/treatment expressed in meaningful terms - such as NNT. I also want my right to make a decision that I feel is right for me without any pressure. If I make a decision (based on accurate information) that goes against recommendations, I expect my decision to be respected.

Currently when it comes to screening and preventive drugs, there is very little regard for informed consent (even the spirit of informed consent). The doctors love to use meaningless hype and scare tactics - n women die annually from this deasese (most of them were screened), you have such and such lifetime risk (screening makes a difference only in small percentage of cases; besides all-cause mortality is still 100%), screening reduces desease-specific mortality by n% (meaningless, unless you consider your chance of dying from the desease within some reasonable time period, also absence of all-cause mortality figures may hide various biases in studies). Overdiagnosis is NEVER mentioned, number needed to screen to save one life (NNT) is never mentioned, true rate of false positives is rarely mentioned. I am afraid, that this will be much worse with P4P. In fact, I am afraid that with doctors' getting paid based on percentage of people who follow all recommendations for preventive care, the doctors will try to get patience to follow these recommendations by any means including outright lies, pressure and simple 'firing' of patients who make different choice.

Those who say that preventive measures save money and so is our responsibility and not our choice - I dare you to prove with numbers that all recommended screening/preventive drugs result in significant savings.  I tried to look for links for mammograms, but most of them provide estimate is amount of money for life saved rather than amount of money saved by less treatment for few patients vs amount of money spent on screening of everyone, false positive evaluation for many, overdiagnosis. Use some reasonable time interval like 10 years not the meaningless life time risk. Dr Rob - if you believe in EBM, why don't you prove what you say rather than just use words "it's been proven" when there is no prove whatsoever and the opposite is likely to be true.

Notice that I am not aruguing against screening, but for choice based on complete and honest information.

You are right I shouldn't have overreacted. I apologize. I really am sorry for the tone of my message.

 But I am just tired of the current mentality that women should be scared into screening or forced into screening and that the women who refuse are irresponsible. I am also worried that P4P will make it more difficult for women to make a choice the doctor may be penalized for - and I believe it is wrong to penalize doctors for women's choices. Also, when discussing P4P you adamantly said that mammograms save money (note - not lives, but money), when this is not really the case. Insurance companies had to be forced by laws to cover it; or they would never do it. 

I do not argue that screeening saves lives - and by the way I read USPSTF report on mammograms in detail and not just the patient version, as well as the PDQ summary of evidence from the NIH web site (I guess I had way too much money on my hands). But while 35% reduction (this is actully higher than what either USPSTF or PDQ estimate) sounds great and may convert to a significant total number of lives saved, it is a relative number which is really meaningless unless one considers what one's risk of dying from the desease is within the next 10 years or so. USPSTF estimated that you need to screen 1200 (or something like it) women in their 50s for 10 years to save one life; 1700 women in their 40s. These numbers sound much less impressive that 35% mortality reduction. If one considers that during the same 10 years, there is a 50% chance of being recalled for a false positive (granted most of these just another mammogram, but some are biopsies), and there is a chance of overdiagnosis that is at least an order of magnitude higher than the mammograms will save your life, the choice of an individual woman becomes less obvious.

Again, I am sorry, I am just really worried about how P4P going to affect personal choice.

I suppose they were idiots then, I was just younger. When I started in medicine I corrected an M.D's mistakes (I'm ancillary professional) once in a blue moon. Now, I correct 8 to 10 to 12 to 15 mistakes a day. WHy? Because, I guess, the doctors are going so fast that they cannot think. That and the ridiculously ignorant foreign M.D.s, how do they ever get a license? Oh, yeah, I forgot, they're cheaper. Hence, their presence in public medical schools all over the country.  But my work has DOUBLED holding everybody's hands, especially the foreign M.D.s, who seem to take such hand-holding for granted.  Make me do the work.  I now hate medicine.